Exploring Alteplase as Concomitant Therapy in Acute Subdural Hematoma Management: A Case Report

Background: Acute subdural hematoma (aSDH) occurs when blood rapidly accumulates under the dura mater, often within minutes to hours of head trauma. If untreated, aSDH may evolve into a chronic subdural hematoma, leading to severe neurologic deficits and long-term morbidity. Standard management involves craniotomy with trepanation, and in extensive cases may require a large craniectomy to evacuate solid clot.
Case Description: A 61-year-old male presented after a fall. Head CT demonstrated a massive right aSDH with a 16 mm midline shift. An initial craniotomy was performed, and a subdural drain was placed. Through this drain, 1 mg of alteplase (tPA) was instilled to liquify the clot. By using alteplase, we avoided the need for a larger craniectomy: the thrombolytic action converted solid hematoma into a liquefied hematoma, allowing maximal clot removal via the existing burr hole before any second surgery.
Clinical and radiologic assessments at 6 weeks showed complete resolution of the hematoma and midline shift, with a Glasgow Coma Scale of 15/15. At 6 months, the patient exhibited full neurologic recovery and good overall health.
Conclusion: In this case, adjunctive alteplase administration via a subdural drain liquified the hematoma and enabled adequate drainage, obviating a more extensive craniectomy. This combined approach warrants further investigation as a minimally invasive adjunct for acute subdural hematoma management.

Alteplase Hematoma Hemorrhage Plasminogen activator