From the Guidelines
A hematoma requires surgical intervention when it is life-threatening, causes significant mass effect, neurological deficits, or continues to expand despite conservative management, as indicated by the most recent guidelines from the American Heart Association/American Stroke Association 1.
Key Indications for Surgical Intervention
- Life-threatening bleeding: intracranial hemorrhage, expanding or uncontrollable bleeding, as emphasized in the guidance on indications for use of direct oral anticoagulants reversal 1
- Bleeding in a critical organ or closed space
- Urgent or emergency surgery or intervention that cannot be delayed in patients with a high risk for procedural bleeding, such as neurosurgery
- Urgent relief surgery for intracranial hemorrhage
Specific Considerations
- For patients with cerebellar ICH, urgent surgical hematoma evacuation with or without external ventricular drainage (EVD) is recommended to reduce mortality in those deteriorating neurologically, with brainstem compression and/or hydrocephalus, or with cerebellar ICH volume ≥15 mL 1
- The decision for surgery should balance the risks of continued compression and secondary injury against surgical complications, considering factors like patient age, comorbidities, anticoagulation status, and neurological condition
Surgical Approaches
- Surgical approaches vary based on location and may include craniotomy, burr hole drainage, or minimally invasive techniques
- Prompt neurosurgical consultation is essential when these criteria are met, as timely intervention can significantly improve outcomes by relieving pressure on brain tissue and preventing secondary injury 1
From the Research
Indications for Surgical Intervention in Hematoma
- Hematomas that are large or expanding, causing significant pressure on surrounding tissues or organs, may require surgical intervention 2
- Hematomas that are symptomatic, such as those causing pain, numbness, or weakness, may also require surgical evacuation 2
- In cases where hematomas are causing necrosis of the overlying skin or tissue ischemia, prompt surgical intervention is necessary to prevent further complications 2
Nonsurgical Management of Hematoma
- Tranexamic acid (TXA) has been shown to be effective in reducing bleeding and promoting resolution of hematomas in certain cases, such as chronic subdural hematomas 3, 4
- TXA may be considered as a nonsurgical option for the treatment of recurrent subdural hematomas following surgical evacuation, particularly in patients for whom additional surgery would add significant morbidity 3
- TXA has also been shown to reduce blood loss and wound hematoma development in lumbar spine surgery, although its effect may not be significant in all types of procedures 5
Specific Considerations
- The decision to administer TXA or perform surgical intervention should be made on a case-by-case basis, taking into account the patient's history, presentation, and prognosis 3
- The optimal dose and timing of TXA administration, as well as the specific indications for its use, are still being studied and refined 6