Clinical Pearls & Morning Reports
Glucocorticoids have been used to treat chronic subdural hematoma. Systematic reviews have concluded that glucocorticoids may be safe and effective when used in addition to surgery, with the aim of reducing the risk of recurrence, or as stand-alone therapy, with the aim of avoiding surgery. Hutchinson et al. conducted a multicenter, randomized, placebo-controlled trial to assess the effect of dexamethasone on outcomes in patients with symptomatic chronic subdural hematoma. Read the NEJM Orginal Article here.
Q: Is the incidence of chronic subdural hematoma changing at all?
A: The incidence of chronic subdural hematoma is increasing owing to an aging population and the use of anticoagulant and antiplatelet medications. Chronic subdural hematoma evacuation has been projected to become the most common cranial neurosurgical operation among adults by the year 2030 in the United States.
Q: How often does subdural hematoma recur in surgically treated patients?
A: Patients with chronic subdural hematoma often present with cognitive impairment, gait disturbance, limb weakness, or headache, and the diagnosis is made on the basis of cranial imaging. Surgical evacuation of the subdural collection remains the main treatment approach for symptomatic patients; however, the hematoma recurs in 10 to 20% of surgically treated patients.
A: The patients in this trial were assigned in a 1:1 ratio to receive a 2-week tapering course of oral dexamethasone, starting at 8 mg twice daily, or placebo. The authors found that the percentage of patients who had a favorable outcome (defined as a score of 0 to 3 on the modified Rankin scale at 6 months) was lower among those who received a 14-day tapering course of dexamethasone than among those who received placebo. In the modified intention-to-treat analysis, a favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group at 6 months, for a between-group difference of –6.4 percentage points (95% confidence interval [CI], –11.4 to –1.4) in favor of the placebo group (P=0.01). Because almost all the patients underwent an initial operation to remove the hematoma, no conclusions could be drawn regarding the effect of dexamethasone as a method of conservative management to avoid surgery.
A: Repeat surgery for recurrence of chronic subdural hematoma was performed in 6 of 349 patients (1.7%) in the dexamethasone group and in 25 of 350 patients (7.1%) in the placebo group, for a between-group difference of 5.4 percentage points in favor of the dexamethasone group; 4 patients underwent multiple operations (1 in the dexamethasone group and 3 in the placebo group). Adverse events of special interest occurred in 41 of 375 patients (10.9%) in the dexamethasone group and in 12 of 373 patients (3.2%) in the placebo group (odds ratio, 3.4 [95% CI, 1.81 to 6.85]), and serious adverse events occurred in 60 of 375 (16.0%) and 24 of 373 (6.4%), respectively (odds ratio, 2.49 [95% CI, 1.54 to 4.15]).