Revision rate and postoperative volume development of chronic subdural hematomas after burr hole craniotomy in combination with tranexamic acid vs. surgery alone – a single-center propensity score-matched analysis

BACKGROUND: Chronic subdural hematoma (cSDH) is a common intracranial hemorrhage in elderly patients and is associated with substantial postoperative recurrence rates. Tranexamic acid (TXA) has been proposed as an adjuvant therapy to reduce recurrence by targeting hyperfibrinolysis; however, its efficacy and impact on hematoma volume evolution remain controversial. METHODS: We performed a retrospective cohort study of adult patients who underwent burr-hole evacuation with subdural drainage for cSDH at a single neurosurgical center between 2012 and 2024. Patients receiving postoperative TXA within 48 h for at least 30 days were compared with patients treated surgically without TXA. Propensity score matching (1:1) was applied to balance baseline characteristics. The primary outcome was revision surgery for recurrent cSDH within 3 months. Secondary outcomes included postoperative hematoma volume evolution and all-cause mortality. RESULTS: After matching, 73 patients were included in each group with well-balanced baseline characteristics. Revision surgery within 90 days occurred less frequently in the TXA group compared with controls (8.2% vs. 19.2%; OR 0.40, 95% CI 0.14-1.12; p = 0.042), although the confidence interval marginally crossed unity, indicating limited precision. Median time to revision was 8 days in the TXA group and 11 days in the control group. Mortality was numerically lower in the TXA group, with no deaths observed, compared with one death (1.4%) in the control group. Preoperative, postoperative, and one-month follow-up hematoma volumes were comparable between groups, and no significant difference in absolute volume reduction was detected. CONCLUSION: Postoperative adjuvant TXA therapy after surgical evacuation of cSDH was associated with a lower rate of recurrence requiring revision surgery, without an observed increase in mortality; however, the confidence interval marginally crossed unity, and the findings should be regarded as hypothesis-generating. TXA did not significantly influence short-term hematoma volume reduction. Prospective randomized studies are needed to confirm these findings and define optimal dosing strategies.