Runze Yang, MD PhD: No financial relationships to disclose
Introduction: The mainstay treatment for symptomatic Chronic subdural hematoma (cSDH) is surgical drainage. Treatment with corticosteroids has shown promise; however, the literature is limited to observational studies with small sample size and studies examining corticosteroids as an adjunct to surgery. The aim of this study was to compare the efficacy of dexamethasone to that of surgery for the primary treatment of cSDH.
Methods: Symptomatic patients with cSDH and GCS of 14 or 15 were eligible. Exclusion criteria included profound motor deficit (< MRC grade 3), more than one seizure, history of psychosis, uncontrolled diabetes, and recommendation for emergent surgery by the admitting surgeon. Participants were randomized to surgery (technique at the discretion of the admitting surgeon) or oral dexamethasone for 14 days. The primary outcome was failure of treatment requiring surgery. CT scan of the head was performed at 4 and 12 weeks.
Results: 63 patients randomized to surgery and 59 patients to dexamethasone. The study groups had similar baseline characteristics (age, comorbidity, anti-coagulant use, SDH volume, Barthel Index of activities of Daily living, Montreal Cognitive Assessment (MoCA) score). Three subjects in the dexamethasone group did not complete the treatment. Data was complete for 89% at 6 months (100% for primary outcome). All subjects were included in the intent to treat analysis. There were more treatment failures in the dexamethasone group (36%) than the surgery group (14%) at 6-months (p < 0.01). Mean cSDH volume did not differ between the groups at 4 and 12 weeks (p>0.05). Barthel Index, MoCA and Modified Rankin Score also did not differ. Adverse event rates were similar (serious events 16%).
Conclusion : In patients presenting with symptomatic cSDH not requiring urgent evacuation, treatment with dexamethasone was associated with clinical and radiological resolution in 64%. The results with surgery were superior with 86% response.
