From the Guidelines
A hematoma requires immediate 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 guidance from the SSC of the ISTH 1.
Key Indications for Surgical Intervention
- Life-threatening bleeding: intracranial hemorrhage, expanding or uncontrollable bleeding
- 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
- Surgical evacuation is often recommended for cerebellar hemorrhage associated with hydrocephalus, brainstem compression, and herniation, despite a lack of randomized evidence 1
- For supratentorial ICH, the usefulness of surgery is not well established, but early hematoma evacuation may be considered as a life-saving measure in deteriorating patients 1
Surgical Approach
- The surgical approach varies based on location and may include craniotomy, burr hole drainage, endoscopic evacuation, or open surgical decompression
- Timing is critical, with most emergency hematoma evacuations performed within hours of diagnosis to prevent irreversible tissue damage from prolonged compression, ischemia, or the inflammatory cascade triggered by blood breakdown products
Conservative Management
- Conservative management with close monitoring may be appropriate for smaller, stable hematomas not causing significant symptoms or neurological deficits
- However, expanding hematomas that fail to respond to reversal of anticoagulation, hematomas causing compartment syndrome with pressures exceeding 30 mmHg, and those resulting in airway compromise or organ compression require immediate surgical intervention 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