Korean J Neurotrauma.  2016 Oct;12(2):101-106. 10.13004/kjnt.2016.12.2.101.

The Effectiveness of Subdural Drains Using Urokinase after Burr Hole Evacuation of Subacute Subdural Hematoma in Elderly Patients: A Prelimilary Report

• Yeo CG
• Jeon WY
• Kim SH
• Kim OL
• Kim MS

• KMID: 2356781
• DOI: http://doi.org/10.13004/kjnt.2016.12.2.101

Abstract

OBJECTIVE
A subdural drain using urokinase after a burr hole hematoma evacuation was performed for subacute subdural hematoma (SASDH), and its effectiveness and safety in elderly patients were evaluated.
METHODS
Between January 2013 and May 2015, subdural drains using urokinase after burr hole hematoma evacuation were performed in 19 elderly patients. The inclusion criteria were as follows: 1) a subdural hematoma occurring between 4 and 20 days after injury; 2) worsening neurological symptoms, from mild to moderate or severe, due to injury during the subacute stage; 3) a mix of solid clots (high-density lighter shadow) and fluid hematoma (low-density darker shadow) on the computed tomography (CT) scan; 4) a score of ≥9 on the Glasgow Coma Scale (GCS) assessed immediately before surgery; and 5) an age of ≥65 years. When the majority of the hematoma was evacuated on the CT, we removed the catheter.
RESULTS
Under local anesthesia, a catheter was inserted into the hematoma through a burr hole. The mean age of the patients was 73.7 years (range, 65-87 years). The mean preoperative GCS score was 11.2 (range, 10-13), and the mean Glasgow Outcome Scale score for all patients was 5 at discharge. No recurrences of hematomas or surgical complications were observed.
CONCLUSION
A subdural drain using urokinase after burr hole hematoma evacuation under local anesthesia is thought to be an effective and safe method of blood clot removal with low morbidity. This surgical method is less invasive for treating elderly patients with SASDH.

Keyword

Subdural hematoma; Elderly patients; Drainage; Urokinase

MeSH Terms

Aged*
Anesthesia, Local
Catheters
Drainage
Glasgow Coma Scale
Glasgow Outcome Scale
Hematoma
Hematoma, Subdural*
Humans
Methods
Recurrence
Urokinase-Type Plasminogen Activator*
Urokinase-Type Plasminogen Activator

Figure

• 

  FIGURE 1 Case 2 was a 71-year-old female patient who presented with headache after a traumatic head injury caused by a slip. (A) At admission, a computed tomography (CT) scan showed a hyperdense hematoma in the subdural space in the right frontotemporal convexity. (B) She had sudden onset left-sided hemiparesis at 17 days after admission. The follow-up CT showed a mixed hypodense and hyperdense subdural hematoma (SDH) and midline shift progression. (C) An immediately postoperative CT scan showed a catheter in the subdural space and a significant amount of residual hematoma with mass effect. (D) A CT scan at postoperative 7 days showed a marked decrease of the SDH and resolution of the mass effect.

• 

  FIGURE 2 Case 6 was a 79-year-old male patient who presented with sensory aphasia and cognitive deterioration after a traumatic head injury caused by a slip. (A) At admission, a computed tomography (CT) scan showed a hyperdense hematoma in the subdural space in the left frontotemporal convexity. (B) He experienced aggravation of his symptoms at 12 days after admission. The follow-up CT showed a mixed hypodense and hyperdense subdural hematoma (SDH) and midline shift progression. (C) An immediately postoperative CT scan showed a catheter in the subdural space and the partial removal of the hematoma. (D) A CT scan at postoperative 7 days showed a marked decrease of the SDH and resolution of the mass effect.

Reference

1. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58:S16–S24. PMID: 16710968.

2. Chen X, Chen W, Ma A, Wu X, Zheng J, Yu X, et al. Frameless stereotactic aspiration and subsequent fibrinolytic therapy for the treatment of spontaneous intracerebral haemorrhage. Br J Neurosurg. 2011; 25:369–375. PMID: 20874455.

3. Gaberel T, Montagne A, Lesept F, Gauberti M, Lemarchand E, Orset C, et al. Urokinase versus Alteplase for intraventricular hemorrhage fibrinolysis. Neuropharmacology. 2014; 85:158–165. PMID: 24846802.

4. Han SB, Choi SW, Song SH, Youm JY, Koh HS, Kim SH, et al. Prediction of chronic subdural hematoma in minor head trauma patients. Korean J Neurotrauma. 2014; 10:106–111. PMID: 27169043.

5. Izumihara A, Orita T, Tsurutani T, Kajiwara K. Natural course of non-operative cases of acute subdural hematoma: sequential computed tomographic study in the acute and subacute stages. No Shinkei Geka. 1997; 25:307–314. PMID: 9125713.

6. Izumihara A, Yamashita K, Murakami T. Acute subdural hematoma requiring surgery in the subacute or chronic stage. Neurol Med Chir (Tokyo). 2013; 53:323–328. PMID: 23708224.

7. Kawamata T, Takeshita M, Kubo O, Izawa M, Kagawa M, Takakura K. Management of intracranial hemorrhage associated with anticoagulant therapy. Surg Neurol. 1995; 44:438–442. discussion 443. PMID: 8629228.

8. Kenning TJ, Dalfino JC, German JW, Drazin D, Adamo MA. Analysis of the subdural evacuating port system for the treatment of subacute and chronic subdural hematomas. J Neurosurg. 2010; 113:1004–1010. PMID: 20509728.

9. Kuwahara S, Fukuoka M, Koan Y, Miyake H, Ono Y, Moriki A, et al. Diffusion-weighted imaging of traumatic subdural hematoma in the subacute stage. Neurol Med Chir (Tokyo). 2005; 45:464–469. PMID: 16195646.

10. Lind CR, Lind CJ, Mee EW. Reduction in the number of repeated operations for the treatment of subacute and chronic subdural hematomas by placement of subdural drains. J Neurosurg. 2003; 99:44–46.

11. Liu L, Shen H, Zhang F, Wang JH, Sun T, Lin ZG. Stereotactic aspiration and thrombolysis of spontaneous intracerebellar hemorrhage. Chin Med J (Engl). 2011; 124:1610–1615. PMID: 21740764.

12. Liu W, Ma L, Wen L, Shen F, Sheng H, Zhou B, et al. Drilling skull plus injection of urokinase in the treatment of epidural haematoma: a preliminary study. Brain Inj. 2008; 22:199–204. PMID: 18240049.

13. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005; 365:387–397. PMID: 15680453.

14. Oertel M, Kelly DF, McArthur D, Boscardin WJ, Glenn TC, Lee JH, et al. Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury. J Neurosurg. 2002; 96:109–116. PMID: 11794591.

15. Patel NY, Hoyt DB, Nakaji P, Marshall L, Holbrook T, Coimbra R, et al. patterns of failure of nonoperative management. J Trauma. 2000; 48:367–374. PMID: 10744271.

16. Rohde V, Uzma N, Rohde I, St Clair E, Samadani U. Fibrinolytic therapy versus craniotomy for anticoagulant-associated intracerebral hemorrhage. Clin Neurol Neurosurg. 2009; 111:518–522. PMID: 19297083.

17. Rosand J, Eckman MH, Knudsen KA, Singer DE, Greenberg SM. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med. 2004; 164:880–884. PMID: 15111374.

18. Singla A, Jacobsen WP, Yusupov IR, Carter DA. Subdural evacuating port system (SEPS)-minimally invasive approach to the management of chronic/subacute subdural hematomas. Clin Neurol Neurosurg. 2013; 115:425–431. PMID: 22763191.

19. Son S, Yoo CJ, Lee SG, Kim EY, Park CW, Kim WK. Natural course of initially non-operated cases of acute subdural hematoma: the risk factors of hematoma progression. J Korean Neurosurg Soc. 2013; 54:211–219. PMID: 24278650.

20. Takeuchi S, Takasato Y, Otani N, Miyawaki H, Masaoka H, Hayakawa T, et al. Subacute subdural hematoma. Acta Neurochir Suppl. 2013; 118:143–146. PMID: 23564121.

21. Vigué B, Ract C, Tremey B, Engrand N, Leblanc PE, Decaux A, et al. Ultra-rapid management of oral anticoagulant therapy-related surgical intracranial hemorrhage. Intensive Care Med. 2007; 33:721–725. PMID: 17260127.