Trial of Dexamethasone for Chronic Subdural Hematoma

Hutchinson, Peter J.; Edlmann, Ellie; Bulters, Diederik; Zolnourian, Ardalan; Holton, Patrick; Suttner, Nigel; Agyemang, Kevin; Thomson, Simon; Anderson, Ian; Al‐Tamimi, Yahia; Henderson, Duncan; Whitfield, Peter; Gherle, Monica; Brennan, Paul M.; Allison, Annabel; Thelin, Eric Peter; Tarantino, Silvia; Pantaleo, Beatrice; Caldwell, Karen; Davis-Wilkie, Carol; Mee, Harry; Warburton, Elizabeth A.; Barton, Garry; Chari, Ajai; Marcus, Hani J.; King, Andrew; Belli, Antonio; Myint, Phyo Kyaw; Wilkinson, Ian B.; Santarius, Thomas; Turner, Carole; Bond, Simon; Kolias, Angelos

doi:10.1056/nejmoa2020473

Cited by 174 publications

(180 citation statements)

References 27 publications

(36 reference statements)

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“…Clearly a rather robust inflammatory response of the brain to the initial SDH is elicited and persists ( 7 , 12 ). Recent trials have been directed at attenuating this response with dexamethasone or atorvastatin ( 19 , 20 , 37 ). There has also been much recent interest in middle meningeal artery (MMA) embolization for the treatment of cSDH.…”

Section: Discussionmentioning

confidence: 99%

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The Mini-Craniotomy for cSDH Revisited: New Perspectives

Chen

Malkasian

et al. 2021

Front. Neurol.

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Background: Chronic subdural hematomas (cSDH) are increasingly prevalent worldwide with the increased aging population and anticoagulant use. Different surgical, medical, and endovascular treatments have had varying success rates. Primary neurosurgical interventions include burr hole drainage of the cSDH and mini-craniotomies/craniotomies with or without fenestration of the inner membrane. A key assessment of the success or failure of cSDH treatments has been symptomatic recurrence rates which have historically ranged from 5 to 30%. Pre-operative prediction of the inner subdural membrane by CT scan was used to guide our decision to perform mini-craniotomies. Release of the inner membrane facilitates the expansion of the brain and likely improves glymphatic flow.Methods: Consecutive mini-craniotomies (N = 34) for cSDH evacuation performed by a single neurosurgeon at a quaternary academic medical center/Level I trauma center from July 2018-September 2020 were retrospectively reviewed. Patient characteristics [age, gender, presenting GCS, GOS, initial CTs noting the inner subdural membrane, midline shift (MLS), cSDH width, inner membrane fenestration, cSDH recurrence, post-operative seizures, infections, length of stay] were extracted from the EMR.Results: Twenty nine patients had mini-craniotomies as primary treatment of the cSDH. Mean age = 68.9 ± 19.7 years (range 22–102), mean pre-operative GCS = 14.5 ± 1.1, mean MLS = 6.75 ± 4.2 mm, and mean maximum thickness of cSDH = 17.7 ± 6.0 mm. Twenty four were unilateral, five bilateral, 34 total craniotomies were performed. Thirty three had inner membrane signs on pre-operative head CTs and an inner subdural membrane was fenestrated in all cases except for the one craniotomy that didn't show these characteristic CT findings. Mean operating time = 79.5 ± 26.0 min. Radiographic and clinical improvement occurred in all patients. Mean improvement in MLS = 3.85 ± 2.69. There were no symptomatic recurrences, re-operations, surgical site infections, or deaths during the 6 months of follow-up. One patient was treated for post-operative seizures with AEDs for 6 months.Conclusion: Pre-operative CT scans demonstrating inner subdural membranes may guide one to target the treatment to allow release of this tension band. Mini-craniotomy with careful fenestration of the inner membrane is very effective for this. Brain re-expansion and re-establishment of normal brain interstitial flow may be important in long term outcomes with cSDH and may be related to the recent interests in brain glymphatics and dural lymphatics.

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Section: Discussionmentioning

confidence: 99%

“…Treatment options for cSDH include surgery (15)(16)(17), observation and medications such as dexamethasone (12,(18)(19)(20) and endovascular obliteration of the meningeal artery (21)(22)(23)(24)(25). There have been numerous studies examining the different procedures.…”

Section: Figure 2 |mentioning

confidence: 99%

The Mini-Craniotomy for cSDH Revisited: New Perspectives

Chen

Malkasian

et al. 2021

Front. Neurol.

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“…In fact, symptomatic CSDH patients showed less favorable outcomes compared to control group under the treatment of oral dexamethasone. 16 Repeating irrigation and drainage are still effective for recurrence of CSDH, however, with appropriate selection, this procedure is an important alternative particularly in the frail, anticoagulated or coagulopathy population. 15 There is ample evidence that contradicts a simple traumatic etiology for chronic subdural hematoma and alludes to a more active inflammatory and angiogenic pathology.…”

Section: Discussionmentioning

confidence: 99%

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Case Series

Alsuwaihel

El-Mughayyar

Archer

et al. 2021

Pan Arab Journal of Neurosurgery

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BACKGROUND: Chronic subdural hematoma (CSDH) represents a common neurosurgical condition particularly in the elderly. Middle meningeal artery embolization (MMAE) has been proposed as a treatment option for this condition.OBJECT: To demonstrate the feasibility of MMAE for the treatment of CSDH avoiding the risk of interrupting anticoagulation and reducing the perioperative risk in a Canadian health care institution. METHODS: A retrospective chart review of patients receiving MMAE as primary treatment for CSDH is presented. Baseline demographics are collected (age, sex, and side of hematoma). Outcomes of interest include hematoma thickness pre-intervention and at follow up, procedural and post-operative complications, and length of hospital stay. Clinical outcomes (subdural hematoma resolution) are supplemented by computed tomography (CT) imaging. RESULTS: Patients (N=4) underwent MMAE for the treatment of CSDH to avoid risk of cessation of anticoagulation and expected perioperative risk. Median age was 74 years. Two patients were on antithrombotic therapy at the time of intervention. Patient follow-up occurred at 1, 3, 6, and 9 months post-operatively. Resolution of symptoms and significant reduction of hematoma thickness was evident (up to 14 mm) at follow-up. Improvement in all cases was confirmed by CT and clinical evaluation. No patients suffered from complications or recurrence. CONCLUSION: The MMAE is a safe and practical treatment for CSDH, even in this rather frail patient cohort with some on anticoagulation.

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“…The prevalence of comorbidities in the cSDH patient population was high (63%), and arterial hypertension, as well as cardiac arrhythmias, accounted for most of them (35% and 21%, respectively). On head CT imaging, cSDH had a median thickness of 21 [15][16][17][18][19][20][21][22][23][24][25] mm, were right-sided in 31%, leftsided in 41%, and bilateral in 28% of cases, while a midline shift was visible in 67% with a median of 6 [2-10] mm. Antithrombotics were present in more than half of all cSDH patients (51%) and were almost equally distributed between only anticoagulant (47%) and only antiplatelet (50%) drugs, with few patients (3%) receiving both.…”

Section: Patient and Treatment Demographicsmentioning

confidence: 99%

“…While not the focus of the current study, the association of peri-operative steroid use (which was not part of our treatment regimen for cSDH) with the necessity of repeat operations has been the focus of recent investigations and is currently under critical discussion: Several reports on beneficial effects of steroids on cSDH recurrence exist, but some authors also observed contradictory and even adverse effects [12,19,24,48]. Correspondingly, the very recently published multicenter, randomized DEX-CSDH trial has reported fewer repeat operations but at the same time also fewer favorable outcomes and more adverse events with a 2-week oral dexamethasone treatment compared to placebo at 6 months [21]. Although more prospective studies are currently underway, especially in more vulnerable patients with chronic comorbidities, the peri-operative administration of steroids should thus be evaluated with caution [29,30].…”

Section: Reoperationmentioning

confidence: 99%

Relevance of comorbidities and antithrombotic medication as risk factors for reoperation in patients with chronic subdural hematoma

et al. 2021

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In an aging Western society, the incidence of chronic subdural hematomas (cSDH) is continuously increasing. In this study, we reviewed our clinical management of cSDH patients and identified predictive factors for the need of reoperation due to residual or recurrent hematomas with a focus on the use of antithrombotic drugs. In total, 623 patients who were treated for cSDH with surgical evacuation between 2006 and 2016 at our department were retrospectively analyzed. Clinical and radiological characteristics and laboratory parameters were investigated as possible predictors of reoperation with univariate and multivariate analyses. Additionally, clinical outcome measures were compared between patients on anticoagulants, on antiplatelets, and without antithrombotic medication. In univariate analyses, patients on anticoagulants and antiplatelets presented significantly more often with comorbidities, were significantly older, and their risk for perioperative complications was significantly increased. Nevertheless, their clinical outcome was comparable to that of patients without antithrombotics. In multivariate analysis, only the presence of comorbidities, but not antithrombotics, was an independent predictor for the need for reoperations. Patients on antithrombotics do not seem to necessarily have a significantly increased risk for residual hematomas or rebleeding requiring reoperation after cSDH evacuation. More precisely, the presence of predisposing comorbidities might be a key independent risk factor for reoperation. Importantly, the clinical outcomes after surgical evacuation of cSDH are comparable between patients on anticoagulants, antiplatelets, and without antithrombotics.

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Trial of Dexamethasone for Chronic Subdural Hematoma

Cited by 174 publications

References 27 publications

The Mini-Craniotomy for cSDH Revisited: New Perspectives

The Mini-Craniotomy for cSDH Revisited: New Perspectives

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Case Series

Relevance of comorbidities and antithrombotic medication as risk factors for reoperation in patients with chronic subdural hematoma

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