Burr hole surgery for acute subdural hematoma with recombinant tissue-type plasminogen activator injected into hematoma cavity: two-patient case report

Standard surgery for acute subdural hematoma (ASDH) is craniotomy with hematoma removal under general anesthesia. However, for the very elderly or those with other high-risk underlying conditions, the usefulness of surgeries such as hematoma irrigation with trephination therapy (HITT) under local anesthesia and endoscopic hematoma removal has been reported. Burr hole surgery such as HITT is performed in some cases, but its hematoma-removal effect is limited. It is selected for temporary decompression in emergency situations or cases where craniotomy is difficult, but the indications for burr hole surgery remain unclear. One method to increase the hematoma-removal rate with burr hole surgery is to inject a hematoma-dissolving agent into the hematoma cavity postoperatively. In this study, we injected recombinant tissue-type plasminogen activator (rt-PA) into the hematoma cavity after acute-phase burr hole surgery in two cases of ASDH involving very elderly, high-risk patients for whom craniotomy under general anesthesia was difficult. Both patients achieved hematoma reduction and completed treatment without hemorrhagic complications, although functional recovery was limited. We considered age and other complications to be major factors hampering functional improvement. In this study, rt-PA injection into the hematoma cavity for ASDH was safely performed, and the hematoma-drainage effect was confirmed, suggesting it may become an effective treatment.