Tranexamic acid to prevent operation in chronic subdural haematoma (TORCH): study protocol for a randomised placebo-controlled clinical trial

A Case Report of Tranexamic Acid for the Treatment of Chronic Subdural Hematoma in an 86-Year-Old Patient

Fibrinolytic and coagulative hyperactivity is proven to have a role in liquefaction and progression of chronic subdural hematoma (CSDH). Tranexamic acid was one of the pharmaceutical options that was explored, as it inhibits the hyper-fibrinolytic activity and reduces the vascular permeability in CSDH, leading to a gradual resolution of the hematoma. In this case study, we present a case of using tranexamic acid for CSDH treatment in an 86-year-old patient with co-morbidities. The complete resolution of the hematoma following using tranexamic acid in this case with no history of recurrence in two years follow-up supports its efficacy in CSDH treatment and may be considered as one of the strategies that help prevent surgeries.

Factors associated with success of conservative therapy in chronic subdural hematoma: a single-center retrospective analysis

INTRODUCTION

Conservative therapy is a viable option for patients with chronic subdural hematoma (cSDH) who express no, or only mild symptoms. It is not clear which factors are associated with success of conservative therapy. This study aims to determine conservative therapy's success rate and to identify features possibly associated with success.

METHODS

A monocenter retrospective cohort study, including cSDH patients treated conservatively (wait-and-watch) from 2012 to 2022, was performed. The primary outcome was success of conservative therapy, defined as 'no crossover to surgery' during the follow-up period. Secondary outcomes were (1) factors associated with success, analyzed with univariate and multivariable logistic regression analyses, (2) 30-day mortality (3) time to crossover and (4) reasons for crossover.

RESULTS

We included 159 patients. Conservative therapy was successful in 96 (60%) patients. Hematoma volume (OR 0.79, 95% CI 0.69-0.92) and hypodense hematoma type (OR 3.57, 95% 1.38-9.23) were associated with success. Thirty-day mortality rate was 5% and the median duration between diagnosis and surgery was 19 days (IQR 8-39). Clinical deterioration was the most frequent reason for crossover (in 61/63 patients, 97%) and was accompanied by radiological hematoma progression in 42 patients (67%).

CONCLUSION

In this selected group of patients, conservative therapy was successful in 60%. Smaller hematoma volume and hypodense hematoma type were associated with success. As time until crossover was approximately three weeks, deploying conservative therapy as primary treatment seems safe and could be rewarding as surgical complications can be avoided. Improvement in patient selection in future cohorts remains warranted.

Administration of Tranexamic Acid After Burr Hole Craniotomy Reduced Postoperative Recurrence of Chronic Subdural Hematoma in a Japanese Regional Population

BACKGROUND

Although tranexamic acid (TXA) has occasionally been used to prevent postoperative recurrence of chronic subdural hematoma (CSDH) after burr hole craniotomy (BC), robust evidence of its efficacy has been lacking.

OBJECTIVE

To assess the efficacy and safety of postoperative oral administration of TXA after BC for CSDH among the elderly.

METHODS

This retrospective, propensity score-matched cohort study was carried out with a large Japanese local population-based longitudinal cohort in the Shizuoka Kokuho Database between April 2012 and September 2020. Patients included were age 60 years or older and had undergone BC for CSDH but were not undergoing dialysis. Covariates were collected from records of the preceding 12 months from the month of first BC, and patients were followed up for 6 months after surgery. The primary outcome was repeat surgery, and the secondary outcome was death or the onset of thrombosis. Data on postoperative TXA administration were collected and compared with controls using propensity score matching.

RESULTS

Of the 8544 patients who underwent BC for CSDH, 6647 were included, with 473 placed in the TXA group and 6174 placed in the control group. After 1:1 matching, repeated BC was found to have been performed in 30 of 465 patients (6.5%) in the TXA group and in 78 of 465 patients (16.8%) in the control group (relative risk, 0.38; 95% CI, 0.26-0.56). No significant difference was observed for death or the onset of thrombosis.

CONCLUSION

Oral administration of TXA reduced the occurrence of repeat surgery after BC for CSDH.

Usage of Tranexamic Acid for Treatment of Subdural Hematomas

The collection of blood in the subdural layer within the cranium is classified as a subdural hematoma. Prevalence of subdural hematomas is most common among older populations with the current standard of treatment being invasive surgical evacuation for patients presenting with acute subdural hematomas with a midline shift greater than 5 mm on computed tomography (CT).Tranexamic acid (TXA) has been identified as an alternative, non-invasive option to treat patients presenting with subdural hematoma who are not suitable for surgical intervention. The presenting case involves a 90-year-old female who arrived with a code stroke with the chief complaint of right lower extremity weakness. A stroke series CT panel revealed a left frontal multiloculated subdural hematoma, measuring 130 mL with mass effect and a midline shift of 7 mm. The patient was recommended a craniotomy for hematoma evacuation or access to hospice for comfort care. A second opinion resulted in the administration of TXA. After the full completion of a TXA course, the patient achieved baseline mobility. The final measurements revealed a final hematoma volume of 10 mL and a midline shift of less than 2 mm. Current literature, as well as the case described, has begun demonstrating the efficacy of the usage of TXA in the reabsorption of subdural hematomas and should encourage further exploration into society guidelines for the usage of TXA as a non-invasive alternative to treat subdural hematomas.