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Dexamethasone versus Surgery for Chronic Subdural Hematoma.

Ishita P Miah1, Dana C Holl1, Jurre Blaauw1

  • 1From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

The New England Journal of Medicine
|June 14, 2023
PubMed
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Dexamethasone treatment for chronic subdural hematoma was not superior to surgery and led to more complications. This study highlights the risks of using glucocorticoids without surgical evacuation for this condition.

Area of Science:

  • Neurosurgery
  • Neurology
  • Pharmacology

Background:

  • The efficacy of glucocorticoids in treating chronic subdural hematoma (CSH) without surgical intervention remains uncertain.
  • CSH is a significant cause of morbidity, particularly in elderly populations.

Purpose of the Study:

  • To compare the noninferiority of dexamethasone versus burr-hole drainage for symptomatic chronic subdural hematoma.
  • To evaluate functional outcomes and complication rates associated with each treatment modality.

Main Methods:

  • A multicenter, open-label, controlled, noninferiority trial comparing a 19-day tapering course of dexamethasone to burr-hole drainage.
  • Random assignment of 252 symptomatic CSH patients (1:1 ratio) with functional outcome assessed by modified Rankin Scale at 3 months.

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  • Trial terminated early due to safety and outcome concerns in the dexamethasone group.

    • Main Results:

    • Dexamethasone did not demonstrate noninferiority to burr-hole drainage, with an adjusted odds ratio of 0.55 (95% CI, 0.34 to 0.90) for better functional outcome.
    • The dexamethasone group experienced significantly more complications (59% vs. 32%) and required additional surgery more often (55% vs. 6%).
    • Secondary outcome measures (Markwalder Grading Scale, Extended Glasgow Outcome Scale) generally supported the primary analysis findings.

    Conclusions:

    • Dexamethasone treatment for chronic subdural hematoma is not noninferior to burr-hole drainage.
    • Glucocorticoid therapy in this context is associated with increased complications and a higher need for subsequent surgical intervention.
    • Current evidence suggests surgical evacuation remains the preferred treatment for symptomatic chronic subdural hematoma.