Nonsurgical treatment of chronic subdural hematoma with tranexamic acid

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Object

Chronic subdural hematoma (CSDH) is a common condition after head trauma. It can often be successfully treated surgically by inserting a bur hole and draining the liquefied hematoma. However, to the best of the authors' knowledge, for nonemergency cases not requiring surgery, no reports have indicated the best approach for preventing hematoma enlargement or resolving it completely. The authors hypothesized that hyperfibrinolysis plays a major role in liquefaction of the hematoma. Therefore, they evaluated the ability of an antifibrinolytic drug, tranexamic acid, to completely resolve CSDH compared with bur hole surgery alone.

Methods

From 2007 to 2011, a total of 21 patients with CSDH seen consecutively at Kuki General Hospital, Japan, were given 750 mg of tranexamic acid orally every day. Patients were identified by a retrospective records review, which collected data on the volume of the hematoma (based on radiographic measurements) and any complications. Follow-up for each patient consisted of CT or MRI every 21 days from diagnosis to resolution of the CSDH.

Results

Of the 21 patients, 3 with early stages of CSDH were treated by bur hole surgery before receiving medical therapy. The median duration of clinical and radiographic follow-up was 58 days (range 28–137 days). Before tranexamic acid therapy was initiated, the median hematoma volume for the 21 patients was 58.5 ml (range 7.5–223.2 ml); for the 18 patients who had not undergone surgery, the median hematoma volume was 55.6 ml (range 7.5–140.5 ml). After therapy, the median volume for all 21 patients was 3.7 ml (range 0–22.1 ml). No hematomas recurred or progressed.

Conclusions

Chronic subdural hematoma can be treated with tranexamic acid without concomitant surgery. Tranexamic acid might simultaneously inhibit the fibrinolytic and inflammatory (kinin-kallikrein) systems, which might consequently resolve CSDH. This medical therapy could prevent the early stages of CSDH that can occur after head trauma and the recurrence of CSDH after surgery.

Abbreviation used in this paper:CSDH = chronic subdural hematoma.

Article Information

Address correspondence to: Hiroshi Kageyama, M.D., Kuki General Hospital, Kamihayami 418-1, Kuki, Saitama 346-0021, Japan. email: kageyamahiroshi29@gmail.com.

Please include this information when citing this paper: published online May 3, 2013; DOI: 10.3171/2013.3.JNS122162.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Changes in the hematoma volumes in 18 patients who received tranexamic acid therapy but did not undergo surgery. Key to the right of the graph lists patients according to their case number.

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    Case 19. CT images obtained after starting tranexamic acid therapy. A: Day 1. B: Day 28. C: Day 78. D: Day 127.

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    Case 13. CT images on Day 1, at the initiation of tranexamic acid therapy.

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    Case 13. CT images at 4 months after starting tranexamic acid therapy.

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    CT images of a patient with CSDH treated with observation only. A: Day 1. B: At 1 month.

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    Fibrinolytic system and kallikrein system. FDP = fibrin degradation products; HMW = high molecular weight.

References

1

CRASH-2 Collaborators Intracranial Bleeding Study: Effect of tranexamic acid in traumatic brain injury: a nested randomised, placebo controlled trial (CRASH-2 Intracranial Bleeding Study). BMJ 343:d37952011

2

Ducloy-Bouthors ASJude BDuhamel ABroisin FHuissoud CKeita-Meyer H: High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care 15:R1172011

3

Dunn CJGoa KL: Tranexamic acid: a review of its use in surgery and other indications. Drugs 57:100510321999

4

Fujisawa HIto HKashiwagi SNomura SToyosawa M: Kallikrein-kinin system in chronic subdural haematomas: its roles in vascular permeability and regulation of fibrinolysis and coagulation. J Neurol Neurosurg Psychiatry 59:3883941995

5

Göksu EAkyüz MUçar TKazan S: Spontaneous resolution of a large chronic subdural hematoma: a case report and review of the literature. Ulus Travma Acil Cerrahi Derg 15:95982009

6

Harada KOrita TAbiko SAoki H: [Coagulation and fibrinolysis in chronic subdural hematoma. Measurement of fibrinopeptides.]. Neurol Med Chir (Tokyo) 29:1131161989. (Jpn)

7

Horikoshi TNaganuma HFukasawa IUchida MNukui H: Computed tomography characteristics suggestive of spontaneous resolution of chronic subdural hematoma. Neurol Med Chir (Tokyo) 38:5275331998

8

Ito HYamamoto SKomai TMizukoshi H: Role of local hyperfibrinolysis in the etiology of chronic subdural hematoma. J Neurosurg 45:26311976

9

Kassell NFTorner JCAdams HP Jr: Antifibrinolytic therapy in the acute period following aneurysmal subarachnoid hemorrhage. Preliminary observations from the Cooperative Aneurysm Study. J Neurosurg 61:2252301984

10

Kawakami YChikama MTamiya TShimamura Y: Coagulation and fibrinolysis in chronic subdural hematoma. Neurosurgery 25:25291989

11

Ker KEdwards PPerel PShakur HRoberts I: Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 344:e30542012

12

Nomura SKashiwagi SFujisawa HIto HNakamura K: Characterization of local hyperfibrinolysis in chronic subdural hematomas by SDS-PAGE and immunoblot. J Neurosurg 81:9109131994

13

Oh HJLee KSShim JJYoon SMYun IGBae HG: Postoperative course and recurrence of chronic subdural hematoma. J Korean Neurosurg Soc 48:5185232010

14

Saito KIto HHasegawa TYamamoto S: Plasmin-alpha 2-plasmin inhibitor complex and alpha 2-plasmin inhibitor in chronic subdural hematoma. J Neurosurg 70:68721989

15

Suzuki MKudo AKitakami ADoi MKubo NKuroda K: Local hypercoagulative activity precedes hyperfibrinolytic activity in the subdural space during development of chronic subdural haematoma from subdural effusion. Acta Neurochir (Wien) 140:2612661998

16

Yamashima TYamamoto SFriede RL: The role of endothelial gap junctions in the enlargement of chronic subdural hematomas. J Neurosurg 59:2983031983

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