LOS ANGELES ― Previous research has led to questions concerning the value of administering the steroid dexamethasone to patients with chronic subdural hematoma before surgery. Now, a small new study offers a twist: it hints that the drug may be helpful as an alternative to surgical drainage of the hematoma in certain cases.
Overall, patients who underwent surgery alone fared better than those who received dexamethasone alone in this randomized trial, with a lower number of patients failing initial treatment requiring surgery. However, almost two thirds of those in the dexamethasone group never required surgery.
The fact that some patients in the dexamethasone group did well without surgery raises questions about whether the drug alone may be appropriate for a subset of patients, said study lead author Runze Yang, MD, PhD, in a presentation here at the American Association of Neurological Surgeons (AANS) 2023 annual meeting. Yang is a resident at the University of Calgary.
"This suggests to us that we should really be focusing more work on looking to dexamethasone as a possible treatment," he said.
Mainstay of Neurosurgery
Care of chronic subdural hematoma ― clots of blood on the surface of the brain that often occur after head trauma ― is a mainstay of neurosurgery. The estimated incidence rate is 1.7 per 100,000 worldwide, and the average age of patients is 76.8 years, according to a 2022 report in The Lancet. Hematoma recurs in an estimated 10.9% to 26.3% of patients after surgery, the report said.
Steroids have been used in addition to surgery in a bid to reduce inflammation that could worsen hematomas. For example, a 2020 study in The New England Journal of Medicine showed that "treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group."
For the new study, a randomized controlled trial, researchers assigned patients with chronic subdural hematoma (Glasgow coma score of 14 or 15) to surgery, using a technique at the discretion of the surgeon (n = 63), or oral dexamethasone (n = 59) for 14 days. The primary outcome was failure of the assigned treatment requiring surgery.
The two groups had similar mean ages (73 and 74, respectively) and gender (75% and 88% female, respectively.) Three of the patients receiving dexamethasone didn't complete the trial.
At 6 months, initial treatment failed in 14% of the surgery patients and 36% of those assigned to dexamethasone (P < .01).
While treatment failure outcomes were different between the groups, they were similar by other measures ― mean hematoma volume at 4 and 12 weeks (P > .05), Barthel index, Montreal cognitive assessment, modified Rankin score, and rate of serious adverse events (16%).
Chan noted that the cognitive assessments improved significantly in both groups. "Whether it's surgery or dexamethasone," he said, "we're making a big difference in these patients' quality of lives."
In the big picture, Yang said, "when you compare surgery to dexamethasone, head-to-head surgery is absolutely better. There's no doubt. But if you look at it another way, 64% of patients treated with dexamethasone didn't need surgery at all."
Moving forward, "future studies may be done to try to distinguish what variables would be able to predict the success or failure of dexamethasone therapy for chronic subdural hematomas," Yang said.
In terms of cost, dexamethasone is a very inexpensive drug. Data about the cost of surgery is outdated: A 2015 report found that operating costs averaged $7588 for patients treated with burr hole procedures and $10,416 for craniotomy patients.
Commenting on the findings was neurosurgeon Peter Hutchinson, MBBS, PhD, of the University of Cambridge in the UK, who led that 2020 study in The New England Journal of Medicine. In an interview, he noted that his team's research linked dexamethasone to side effects such as psychosis, confusion, and diabetes.
Hutchinson said the question now is whether to explore dexamethasone at lower doses. "I think energy would be better directed looking at other therapies that work against inflammation and have fewer complications and side effects," he said.
No study funding was reported. Yang and Hutchinson have no disclosures.
American Association of Neurological Surgeons (AANS) 2023 Annual Meeting: Young Neurosurgeon Research Forum. Presented April 21, 2023.
Lead image: iEM/Flickr
Image 1: University of Calgary
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Cite this: Steroid May Benefit Some With Chronic Subdural Hematoma - Medscape - Apr 24, 2023.