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Risk Factor Analysis of the Conservative Treatment in Chronic Subdural Hematomas: A Substudy of the ATOCH Trial
Dong Wang1, Ye Tian1,2, Huijie Wei1
1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
Insights
For chronic subdural hematomas (CSDH), higher hematoma volume and lower cholesterol predict worse outcomes with atorvastatin. A volume over 68.5 ml suggests a higher chance of needing surgery.
Area of Science:
- Neurosurgery
- Neurology
- Pharmacology
Background:
- Chronic subdural hematomas (CSDH) pose a significant clinical challenge.
- Conservative management, including wait-and-observation and pharmacotherapy, is an option for select CSDH patients.
- Identifying risk factors for treatment failure is crucial for optimizing patient care.
Purpose of the Study:
- To analyze risk factors for disease progression in CSDH patients.
- To compare outcomes between conservative treatment with atorvastatin and a placebo (wait-and-observation).
- To identify predictors of conservative treatment efficacy.
Main Methods:
- 196 CSDH patients were randomized into atorvastatin (98) and placebo (98) groups.
- Receiver operating characteristic (ROC) curve analysis identified optimal hematoma volume thresholds.
- Univariate and multivariate analyses assessed baseline indicators for treatment outcomes.
Main Results:
- Lower total cholesterol, higher hematoma volume, and greater midline shift were independent risk factors for worse outcomes with atorvastatin.
- Higher hematoma volume was the sole independent risk factor for spontaneous absorption in the placebo group.
- An optimal hematoma volume threshold of 68.5 ml was identified (sensitivity 73.5%, specificity 74%) for predicting the need for surgery.
Conclusions:
- Higher total cholesterol, lower hematoma volume, and less midline shift predict successful atorvastatin monotherapy.
- Higher hematoma volume is the primary risk factor for poor outcomes in non-pharmacotherapy CSDH management.
- An initial hematoma volume exceeding 68.5 ml aids in risk assessment and treatment decision-making for CSDH.
Introduction:
The objective of the study was to analyze the risk factors for worsening of the disease progression in patients with chronic subdural hematomas (CSDH) during wait-and-observation treatment regimen and conservative treatment with atorvastatin.
Methods:
A total of 196 patients with CSDH were recruited (98 in the atorvastatin group and 98 in the blank placebo group). Receiver operating characteristic (ROC) curve analysis was used to identify the optimal cutoff for the hematoma volume by testing surgical and nonsurgical outcomes. Other measures, including univariate and multivariate analyses, were performed to identify the potential significant factors indicative of the outcome of therapeutic efficacy of conservative treatment through the characteristics of the baseline indicators at enrollment.
Results:
Over a median treatment duration of 2 months, lower total cholesterol, higher hematoma volume, and more midline shift were independent risk factors for worse outcomes of atorvastatin treatment for CSDH, and only a higher hematoma volume was an independent risk factor for spontaneous absorption in the placebo group. ROC analysis of all of the data showed that the optimal threshold of hematoma volume was 68.5 ml (sensitivity 73.5%, specificity 74%) in response to the greatest chance of switching to surgery.
Conclusions:
Critical independent predictors of atorvastatin monotherapy treatment success included higher total cholesterol, lower hematoma volume, and less midline shift in atorvastatin monotherapy, and higher hematoma volume was the only independent risk factor in close follow-up observation patients without any pharmacotherapy. Initial hematoma volume more than 68.5 ml may help clinicians to determine individual risk assessments and to make optimal treatment decisions.
Trial Registration:
http://www.
Clinicaltrials:
gov . Identifier NCT02024373.
