1. Management severe subdural Hematoma in Neonate: intratecal infusion streptokinase for clot lysis. Larionov S.N., Sorokovikov V., A., Novozilov V.A. Department Neurosurgery of Scientific Center of Reconstructive and Restorative Surgery of Eastern-Siberian Scientific Center Siberian Branch of Russian Academy of Medical Sciences, Bortzov Revolutsii 1, Irkutsk, Russia Status: January 5th, 2005

2.   The subdural hematomas (SDH) involving more than one lobe of the brain among full-term infants have the potential to cause death or lifelong disability

3. Etiological factors   Sinovenous thrombosis   Birth-related trauma   Maternal infection   Impairments in coagulation Hypoxic-ischemic injury

4. The purpose  The purpose of this report is to document the management and outcomes of newborn treated for SH by drainage and subdural streptokinase lavage.

5. Case presentation  A newborn female was born at a gestational age of 40 weeks, weighing 3780 g. A 1-month-old baby was hospitalized for dyspnoea lasting four hours at the medical ward of infection hospital. The baby was observed to be listless and lethargic and to have a poor suck. The anterior fontanelle was tense. Seizures developed.

6. CT of the brain found an extensive panhemispheral SDH on the left, sings sigmoid and transverse sinus thrombosis

7. General examination  Hemograms revealed that neonate was anemic with low hemoglobins, low platelets, abnormal prothrombin and partial thromboplastin times. Serologic testing to CNS viral infection (Epstein–Barr virus (EBV), Mycoplasma pneumoniae, Herpes simplex, varicella, influenza A and B, mumps, cytomegalovirus, and rubella) was negative.

8. Surgical treatment   Percutaneous subdural tapping (Romodanov A.P., 1987)   Shunting of hematoma in peritoneal cavity (Hwang S. K., Kim S. L., 2000)   Shunting of hematoma in subgaleal spaces (Miyake H., 2002)   Intrathecal Administration of Urokinase for clot lysis – Experimental Study (Hariton G B., et al., 1993)

9. TREATMENT  A small dural incision is made the lateral edge of the anterior fontanelle, a silicone catheter with an external diameter of 1.7 mm was placed into a hematoma. Second incision was done in occipital area with trephination, dura mater was incised and clot blood was observed, and a hematoma is external drainage 2.0 mm a silicone catheter. Some hemorrhagic fluid was withdrawn and 25,000 units streptokinase was infused at 0.5 ml/h for three days.

10. A CT scan taken on day 4 revealed a residual fluid collection in subdural space

11.  For the following 72 hours, the drains conducted away a brown colliquation with fresh blood admixed (about 150 ccm). After three days, the drainage was reduced (12 – 15 ccm). The external drainage was removed and subdurosubgaleal shunts were placed.  The patient showed a rapid improvement and full resolved fluid collection.

12. Control MRI and MRA demonstrated didn’t fluid collection in subdural space and recanalisation of the sigmoid and transverse sinuses

13. Conclusion  The study suggests that subdural infusion of UK may have equal safety and efficacy in lysing and following drainage subdural hematoma in newborn. Moreover, the subgaleal space seems to be a satisfy site for temporary absorption not only CSF, but and lysing clot of blood.