Document resource
Introduction Chronic subdural hematoma (cSDH) is a common neurosurgical condition with diverse management strategies. Across all treatment modalities, residual hematoma—whether following surgical evacuation or because of subdural drain failure—is a common problem with no consensus regarding optimal management. Adjunctive use of urokinase has been suggested to reduce recurrence rates and minimize postoperative hematoma volume; however, data regarding the use of tissue plasminogen activator (tPA) for cSDH is limited. Given the superior fibrin-specificity and established safety profile of tPA supported by data from ICH and IVH applications, the aim of this study was to evaluate the safety and efficacy of tPA-mediated rescue thrombolysis in the management of residual chronic subdural hematoma.Methods A systematic review and meta-analysis of the literature were conducted to identify studies reporting subdural application of tPA in the rescue management of cSDH. Institutional records of patients treated with rescue tPA between 2016 and 2026 were reviewed and subsequently pooled with cases from the literature for analysis. A subgroup analysis was performed to compare outcomes between patients with and without adjuvant middle meningeal artery embolization (MMAE) to assess the impact of endovascular therapy.Results A total of 103 patients with 117 cSDH were treated with tPA for residual hematoma following operative intervention. Fifteen patients (14.6%) also underwent adjunctive MMAE. Mean age was 71.0 years. Thirty (29%) patients were on anticoagulant therapy at presentation. Average cSDH diameter at presentation was 20.1 mm with an average midline shift (MLS) of 8.1mm. Average diameter of residual was 16.1mm and MLS was 7.4mm, representing a 20% and 9% reduction in diameter and MLS, respectively.Following tPA administration, there were no reports of acute hemorrhagic complications, need for acute rescue surgery, or intracranial infection. Median number of tPA doses administered was 1 and median dose was 1mg. The acute response to tPA administration was characterized by a 61% reduction in diameter (weighted mean 7.9mm, n=71) and 68% reduction in MLS (weighted mean 2.6mm, n=58). At mean final follow-up of 29 days, there was a cumulative 77% reduction in diameter (weighted mean 4.5mm, n=25) and 96% reduction in MLS (weighted mean 0.3mm, n=25) compared to preoperative size. 90-day need for rescue surgery, neurological mortality, and all-cause mortality was 1%, 2%, and 5%, respectively. In patients with long-term follow up data, a statistically significant reduction in diameter at final follow-up was identified when comparing patients who underwent adjuvant MMAE and those who did not (82% vs 63%, p=0.03).Conclusion In this series, use of subdural tPA as a rescue therapy for residual cSDH was not associated with adverse events, supporting its safety as a rescue strategy following incomplete surgical evacuation. Adjunctive tPA was associated with an immediate and sustained decrease in subdural diameter and midline shift withlow requirements for delayed rescue surgery. Subgroup analysis demonstrated greater long-term radiographic improvement in patients undergoing adjunctive MMAE suggesting a synergistic role for combined surgical and endovascular therapy in optimizing cSDH resolution.Acknowledgements The Segal Family Foundation provides grant support for the Segal Family Internship in Cerebrovascular Medicine.Disclosures N. Lam: None. K. Vinn: None. I. Maiewski: None. R. Wong: None.