Tailored Tissue Plasminogen Factor Injection via Subdural Catheter for Subacute Subdural Hematoma in an Elderly Patient: A Case Report and Literature Review

Abstract

This report presents an 89-year-old patient with subacute subdural hematoma (SDH) treated with local anesthesia via burr-hole trephination (BHT) and subdural drain placement, followed by liquefaction of the hematoma using the fibrinolytic agent, tissue plasminogen activator (tPA). Initially, the patient presented with acute post-trauma SDH without neurological symptoms, for which conservative treatment was administered. About a week later, the patient developed hemiplegia and progressed to a stuporous state. Radiographic evidence indicated that the subacute SDH had evolved into a chronic stage with an increased mass effect, causing new neurological deficits. Although craniotomy was considered, general anesthesia was not performed at the caregiver's request. After BHT, a subdural catheter was placed, but initial drainage was minimal. tPA was then administered to promote liquefaction and drainage. Follow-up computed tomography of the brain confirmed significant drainage of the hematoma. The patient subsequently recovered consciousness and motor function. This report discusses a less-invasive alternative for managing symptomatic subacute SDH. My approach of combining BHT with fibrinolytic therapy using tPA facilitated effective evacuation of the hematoma with minimal surgical intervention. Here, I present a case where tPA was used, detailing the methodology, imaging findings, and clinical outcomes of fibrinolytic therapy.

Keywords: Catheterization; Hematoma, subdural, acute; Subdural space; Tissue plasminogen activator.

FIGURE 1. Serial noncontrast CT, pre-operative. (A) Initial brain CT, axial view. (B) Initial brain CT, coronal view. (C) Follow-up brain CT, performed 10 days later, axial view. (D) Follow-up brain CT, performed 10 days later, coronal view.

CT: computed tomography.

FIGURE 2. Brain CT to verify the catheter tip position. (A) Immediate post-operative brain CT, axial view. (B) Immediate post-operative brain CT, coronal view. (C) Immediate post-operative brain CT, sagittal view. (D) Follow-up brain CT scan on postoperative day 2, axial view. (E) Follow-up brain CT scan on postoperative day 2, coronal view. (F) Follow-up brain CT scan on postoperative day 2, sagittal view. (G) Follow-up brain CT scan on postoperative day 4, axial view. (H) Follow-up brain CT scan on postoperative day 4, coronal view. (I) Follow-up brain CT scan on postoperative day 4, sagittal view.

CT: computed tomography.

FIGURE 3. Postoperative drainage volume over time.

tPA: tissue plasminogen activator.