Download PDF
CC BY 4.0 · Indian Journal of Neurotrauma
DOI: 10.1055/s-0044-1779288
Review Article

How Dexamethasone Affects Necessity for Surgical Intervention for Chronic Subdural Hematoma: Systematic Review and Meta-Analysis

Amit Agrawal 
1   Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh, India
,
Amit Gupta
2   Department of Neurosurgery, GSVM Medical College, Kanpur, Uttar Pradesh, India
,
Rakesh Mishra
3   Department of Neurosurgery, Bhopal Memorial Hospital and Research Centre, Bhopal, Madhya Pradesh, India
,
Oday Atallah 
4   Department of Neurosurgery, Hannover Medical School, Hannover, Germany
,
Md Moshiur Rahman 
5   Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
,
Saikat Das
6   Department of Radiation Oncology, All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh, India
,
Luis Rafael Moscote-Salazar 
7   Neurocritical Care, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia
,
Prasad Krishnan 
8   Department of Neurosurgery, National Neurosciences Centre, Calcutta, West Bengal, India
,
Ved Prakash Maurya 
9   Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
› Author Affiliations Funding None.
› Further Information
   Permissions and Reprints

Abstract

The effectiveness of dexamethasone in managing chronic subdural hematoma (cSDH) patients remains uncertain although the drug is widely used in this condition. The present systematic review aims to understand the role of dexamethasone in reducing the need for surgery in cSDH patients. This study was conducted as per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the electronic databases of PubMed, SCOPUS, Cochrane Central Register of Controlled Trials (the Cochrane Library), and ScienceDirect with a predefined search strategy. The population consisted of cSDH patients older than 18 years and treated primarily with dexamethasone. The primary outcome was the need for surgery after dexamethasone therapy in cSDH patients. The meta-analysis of a group of patients was done with the invariance method to estimate the pooled odds of the requirement for surgery after dexamethasone therapy. In the studies with a one-to-one comparison of dexamethasone with placebo/observation, the Mantel–Haenszel statistics were used to determine the odds of surgery. The quality of the studies was assessed with the Newcastle–Ottawa scale (NOS) and the Cochrane risk of bias tool was used to assess the risk of bias in randomized studies. In total, 598 studies were obtained from the database search and after applying the inclusion and exclusion criteria, 10 studies were finally selected for the qualitative and quantitative synthesis. One of the 10 studies was a randomized controlled trial (RCT), while the rest were observational studies. There were 653 patients who received the primary dexamethasone therapy. Of these, 388 patients did not require surgery, while 256 needed surgeries after the therapy. The pooled estimate of requirement for surgery after dexamethasone therapy was 0.41, with a 95% confidence interval of 0.37 to 0.45. A meta-analysis of the one-to-one comparison from three included studies showed a higher need of surgery in the (comparator) placebo/observation group than in the dexamethasone group with odds ratio of 7.16 (95% confidence interval: 2.21–23.13, with p = 0.0001). In addition, we identified the gaps in literature, and the complications and mortality reported in the studies. Dexamethasone is effective in reducing the requirement for surgery in some selected cSDH cases, although many patients still require surgical intervention.

Keywords

dexamethasone - nonsurgical - subdural hematoma - chronic - meta-analysis


Publication History

Article published online:
31 January 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Ahmed OEF, Nagaty A, Helmy M, El Molla ST. The use of dexamethasone therapy for conservative management of chronic subdural hematomas: a question about efficacy and safety. Egypt J Neurol Psychiat Neurosurg 2023; 59 (01) 48
    Google Scholar
  • 2 Kolias AG, Chari A, Santarius T, Hutchinson PJ. Chronic subdural haematoma: modern management and emerging therapies. Nat Rev Neurol 2014; 10 (10) 570-578
    Google Scholar
  • 3 Kudo H, Kuwamura K, Izawa I, Sawa H, Tamaki N. Chronic subdural hematoma in elderly people: present status on Awaji Island and epidemiological prospect. Neurol Med Chir (Tokyo) 1992; 32 (04) 207-209
    Google Scholar
  • 4 Santarius T, Hutchinson PJ. Chronic subdural haematoma: time to rationalize treatment?. Br J Neurosurg 2004; 18 (04) 328-332
    Google Scholar
  • 5 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
    Google Scholar
  • 6 Higgins JP, Thomas J, Chandler J. et al. Cochrane Handbook for Systematic Reviews of Interventions. Chichester, UK:: John Wiley & Sons; 2019
    Google Scholar
  • 7 Markwalder TM, Steinsiepe KF, Rohner M, Reichenbach W, Markwalder H. The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage. J Neurosurg 1981; 55 (03) 390-396
    Google Scholar
  • 8 Higgins JPT, Altman DG, Gøtzsche PC. et al; Cochrane Bias Methods Group, Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928
    Google Scholar
  • 9 Wells G, Shea B, O'Connell D. et al. Newcastle-Ottawa Quality Assessment Scale Cohort Studies. Ottawa:: University of Ottawa;; 2014
    Google Scholar
  • 10 AbdelFatah MAR. Medical management of chronic subdural hematoma with low-dose dexamethasone: a case series study. NPG Neurol Psychiatr Geriatr 2023; 23 (133) 29-33
    Google Scholar
  • 11 Chan DYC, Sun TFD, Poon WS. Steroid for chronic subdural hematoma? A prospective phase IIB pilot randomized controlled trial on the use of dexamethasone with surgical drainage for the reduction of recurrence with reoperation. Chin Neurosurg J 2015; 1 (01) 1-5
    Google Scholar
  • 12 David RJ, Tan E, Teo MK. Trial of dexamethasone for chronic subdural hematoma. Br J Neurosurg 2023; 37 (02) 241
    Google Scholar
  • 13 Davis-Wilkie C. A randomised, double blind, placebo-controlled trial of a two-week course of dexamethasone for adult patients with a symptomatic chronic subdural haematoma (Dex-CSDH trial). 2019. DOI: 10.1002/central/CN-01933478
    Google Scholar
  • 14 Diener HC. Dex-CSDH trial: dexamethasone for chronic subdural hematoma. Arzneimitteltherapie 2021; 39 (03) 84-85
    Google Scholar
  • 15 Edlmann E, Giorgi-Coll S, Thelin EP, Hutchinson PJ, Carpenter KLH. Dexamethasone reduces vascular endothelial growth factor in comparison to placebo in post-operative chronic subdural hematoma samples: a target for future drug therapy?. Front Neurol 2022; 13: 952308
    Google Scholar
  • 16 Edlmann E, Thelin EP, Caldwell K. et al; Dex-CSDH trial collaborative and BNTRC collaborative.. Dex-CSDH randomised, placebo-controlled trial of dexamethasone for chronic subdural haematoma: report of the internal pilot phase. Sci Rep 2019; 9 (01) 5885
    Google Scholar
  • 17 Fan Y, Wang D, Rao C. et al. Atorvastatin combined with low-dose dexamethasone treatment protects endothelial function impaired by chronic subdural hematoma via the transcription factor KLF-2. Drug Des Devel Ther 2020; 14: 3291-3299
    Google Scholar
  • 18 Fan YS, Wang B, Wang D. et al. Atorvastatin combined with low-dose dexamethasone for vascular endothelial cell dysfunction induced by chronic subdural hematoma. Neural Regen Res 2021; 16 (03) 523-530
    Google Scholar
  • 19 Holl D, Miah IP, Blaauw J. et al. Dexamethasone versus burr-hole craniostomy for chronic subdural hematoma; the DECSA trial. Brain Spine 2021; 1: 100648
    Google Scholar
  • 20 Huang J, Li L, Zhang J. et al. Treatment of relapsed chronic subdural hematoma in four young children with atorvastatin and low-dose dexamethasone. Pharmacotherapy 2019; 39 (07) 783-789
    Google Scholar
  • 21 Hutchinson PJ, Edlmann E, Bulters D. et al; British Neurosurgical Trainee Research Collaborative, Dex-CSDH Trial Collaborators. Trial of dexamethasone for chronic subdural hematoma. N Engl J Med 2020; 383 (27) 2616-2627
    Google Scholar
  • 22 Jong JD. Dexamethasone versus burr hole craniostomy for symptomatic chronic subdural hematoma (DECS). 2019. DOI: 10.1002/central/CN-01933494
    Google Scholar
  • 23 Kolias AG. A randomised, double blind, placebo-controlled trial of a two-week course of dexamethasone for adult patients with a symptomatic chronic subdural haematoma. 2019. DOI: 10.1002/central/CN-01933497
    Google Scholar
  • 24 Mebberson K, Colditz M, Marshman LAG, Thomas PAW, Mitchell PS, Robertson K. Prospective randomized placebo-controlled double-blind clinical study of adjuvant dexamethasone with surgery for chronic subdural haematoma with post-operative subdural drainage: interim analysis. J Clin Neurosci 2020; 71: 153-157
    Google Scholar
  • 25 Qian Z, Yang D, Sun F, Sun Z. Risk factors for recurrence of chronic subdural hematoma after burr hole surgery: potential protective role of dexamethasone. Br J Neurosurg 2017; 31 (01) 84-88
    Google Scholar
  • 26 Rudiger A, Ronsdorf A, Merlo A, Zimmerli W. Dexamethasone treatment of a patient with large bilateral chronic subdural haematomata. Swiss Med Wkly 2001; 131 (25–26): 387
    Google Scholar
  • 27 Saul H, Gursul D, Cassidy S, Hutchinson P, Kolias A. Dexamethasone should not be given to people with a chronic subdural haematoma. BMJ 2022; 377: o1302
    Google Scholar
  • 28 Simon A. Chronic subdural hematoma: is dexamethasone safe and effective?. Neurologie Up2date 2021; 4 (02) 111-112
    Google Scholar
  • 29 Sioutas GS, Mannam SS, Corral Tarbay A. et al. dexamethasone and statins in patients undergoing primary middle meningeal artery embolization for chronic subdural hematoma: a propensity-matched study in the TriNetX research network. World Neurosurg 2023; 176: e83-e90
    Google Scholar
  • 30 Tariq J, Bhatti SN. Adjunctive postoperative course of dexamethasone in chronic subdural hematoma: effect on surgical outcome. Pak J Med Sci 2021; 37 (07) 1877-1882
    Google Scholar
  • 31 Vetter C. Chronic subdural hematoma: poorer clinical outcome in a therapy with dexamethasone. Dtsch Arztebl Int 2021; 118 (26) A-1315
    Google Scholar
  • 32 Wang D, Fan Y, Ma J. et al. Atorvastatin combined with dexamethasone promote hematoma absorption in an optimized rat model of chronic subdural hematoma. Aging (Albany NY) 2021; 13 (22) 24815-24828
    Google Scholar
  • 33 Wang D, Gao C, Xu X. et al. Treatment of chronic subdural hematoma with atorvastatin combined with low-dose dexamethasone: phase II randomized proof-of-concept clinical trial. J Neurosurg 2020; 134 (01) 235-243
    Google Scholar
  • 34 Yuan J, Li Y, Liu X. et al. Atorvastatin plus low-dose dexamethasone may be effective for leukemia-related chronic subdural hematoma but not for leukemia encephalopathy: a report of three cases. Front Oncol 2021; 11: 628927
    Google Scholar
  • 35 Zhang Y, Chen S, Xiao Y, Tang W. Effects of dexamethasone in the treatment of recurrent chronic subdural hematoma. World Neurosurg 2017; 105: 115-121
    Google Scholar
  • 36 Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A, Galacho-Harriero AM, Fernández-Arconada O. Dexamethasone treatment in chronic subdural haematoma. Neurocirugia (Astur) 2009; 20 (04) 346-359
    Google Scholar
  • 37 Fountas K, Kotlia P, Panagiotopoulos V, Fotakopoulos G. The outcome after surgical vs nonsurgical treatment of chronic subdural hematoma with dexamethasone. Interdiscip Neurosurg 2019; 16: 70-74
    Google Scholar
  • 38 Holl DC, Fakhry R, Dirven CMF. et al. Surgery after primary dexamethasone treatment for patients with chronic subdural hematoma: a retrospective study. World Neurosurg 2022; 162: e358-e368
    Google Scholar
  • 39 Miah IP, Blanter A, Tank Y. et al. Change in hematoma size after dexamethasone therapy in chronic subdural hematoma subtypes: a prospective study in symptomatic patients. J Neurotrauma 2023; 40 (3–4): 228-239
    Google Scholar
  • 40 Miah IP, Herklots M, Roks G. et al. Dexamethasone therapy in symptomatic chronic subdural hematoma (DECSA-R): a retrospective evaluation of initial corticosteroid therapy versus primary surgery. J Neurotrauma 2020; 37 (02) 366-372
    Google Scholar
  • 41 Papacocea T, Popa E, Dana T, Papacocea R. The usefulness of dexamethasone in the treatment of chronic subdural hematomas. Farmacia 2019; 67 (01) 140-145
    Google Scholar
  • 42 Prud'homme M, Mathieu F, Marcotte N, Cottin S. A pilot placebo controlled randomized trial of dexamethasone for chronic subdural hematoma. Can J Neurol Sci 2016; 43 (02) 284-290
    Google Scholar
  • 43 Sun TF, Boet R, Poon WS. Non-surgical primary treatment of chronic subdural haematoma: preliminary results of using dexamethasone. Br J Neurosurg 2005; 19 (04) 327-333
    Google Scholar
  • 44 Thotakura AK, Marabathina NR. Nonsurgical treatment of chronic subdural hematoma with steroids. World Neurosurg 2015; 84 (06) 1968-1972
    Google Scholar
  • 45 Dran G, Berthier F, Fontaine D, Rasenrarijao D, Paquis P. Effectiveness of adjuvant corticosteroid therapy for chronic subdural hematoma: a retrospective study of 198 cases. Neurochirurgie 2007; 53 (06) 477-482
    Google Scholar
  • 46 Berghauser Pont LM, Dammers R, Schouten JW, Lingsma HF, Dirven CM. Clinical factors associated with outcome in chronic subdural hematoma: a retrospective cohort study of patients on preoperative corticosteroid therapy. Neurosurgery 2012; 70 (04) 873-880 , discussion 880
    Google Scholar
  • 47 Bender MB, Christoff N. Nonsurgical treatment of subdural hematomas. Arch Neurol 1974; 31 (02) 73-79
    Google Scholar
  • 48 Vaquero J, Zurita M, Cincu R. Vascular endothelial growth-permeability factor in granulation tissue of chronic subdural haematomas. Acta Neurochir (Wien) 2002; 144 (04) 343-346 , discussion 347
    Google Scholar
  • 49 Glover D, Labadie EL. Physiopathogenesis of subdural hematomas. Part 2: Inhibition of growth of experimental hematomas with dexamethasone. J Neurosurg 1976; 45 (04) 393-397
    Google Scholar
  • 50 Ito H, Komai T, Yamamoto S. Fibrinolytic enzyme in the lining walls of chronic subdural hematoma. J Neurosurg 1978; 48 (02) 197-200
    Google Scholar
  • 51 Labadie EL, Glover D. Local alterations of hemostatic-fibrinolytic mechanisms in reforming subdural hematomas. Neurology 1975; 25 (07) 669-675
    Google Scholar
  • 52 Suzuki J, Takaku A. Nonsurgical treatment of chronic subdural hematoma. J Neurosurg 1970; 33 (05) 548-553
    Google Scholar