Use of Local Fibrinolysis in Surgical Treatment of Traumatic Intracranial Hematomas

V.V. Krylov, S.A. Burov, A.E. Talypov, I.E. Galankina

(Sklifosovsky Research Institute of Emergency Care, Moscow;
Moscow State Medical-Stomatologic Institute, Moscow)

The research goal was studying possible use of local fibrinolysis for surgical removal of traumatic intracranial hematomas of different localization.

Materials and Methods. There were 21 cases (17 males and 4 females), who underwent surgical treatment of traumatic intracranial hematomas of different localization with the help of local fibrinolysis. A mean age was 42±1 years. Two patients were operated for acute epidural hematomas of 25 cm3 and 41 cm3 (a mean volume of 32±2 cm3); 12 cases had acute subdural hematomas of 30-65 cm3 (a mean volume of 47±2 cm3); intracerebral hematomas of 28-37 cm3 (a mean volume of 32±2 cm3) were diagnosed in 3 casualties. Two cases were operated for multiple traumatic hematomas. One of them had bilateral epidural hematomas of subtentorial localization (25 cm3 and 38 cm3) and the second bilateral intracerebral hematomas of frontal lobes (13 cm3 and 18 cm3).

The cases were subject to clinical-neurological examination with assessment of a level of consciousness inhibition according to the Glasgow Coma Scale (GCS), CT on admission and 12, 24, 48 and 72 hours after fibrinolysis, monitoring of intracranial pressure. Topor (Glasgow Coma score of 12-13) and spoor (Glasgow Coma score of 9) were watched in 17 and 4 cases respectively on admission. A neurological status of all the cases was characterized by moderate meningeal, dislocation (anisocoria, paresis of a look in an upward direction, pathologic reflexes) and focal (anisoreflexia) symptoms; besides, there were signs of intracranial hypertension (venous plethora and initial engorgement of optic disks, intracranial pressure of 28-35 mm Hg). Severe contralateral hemiparesis was revealed in 3 cases with intracerebral hematomas.

Surgical treatment consisted in making a burr hole in hematoma projection with its subsequent fibrinolysis and aspiration. Streptokinase and recombinant prourokinase were used as fibrinolytic drugs.

Results. Complete removal of intracranial hematomas, using fibrinolysis, was achieved in all 21 patients. Hematomas were evacuated 12 (2 cases), 24 (10 cases), 48 (7 cases) and 72 (2 cases) hours after operation. A state of 18 patients (86%) was satisfactory on their discharge; 2 cases (9.5%) had gross focal neurological symptoms. There was one fatal outcome (8.5%). Hemorrhage relapses, demanding repeated intervention, were observed in 2 cases (9.5%).

Conclusion. Fibrinolysis can be used for removal of traumatic hematomas in cases, being in a compensated state, or at an initial stage of dislocation syndrome decompensation.