Using the anti-inflammatory effect of dexamethasone to treat chronic subdural hematoma instead of burr-hole craniostomy
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Reviewed by Dat Tien Nguyen, B.A, ScM.
Translated by Nhi Phuong Quynh Le, B.A. |
Posted on July 17th, 2023
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Over the past decades, the prevalence of chronic subdural hematoma has been increasing in many developed nations. This can be explained by the aging of the population and the usage of anticoagulants to treat cardiovascular conditions. Burr-hole craniostomy is needed to drain the hematoma; this is an effective procedure but there is an increased risk of death. It is hypothesized that the inflammatory reaction exacerbates the hematoma by accumulating liquid and increasing clotting incidence. Thus, a study was conducted to investigate the potential usage of dexamethasone in treating chronic subdural hematoma
The clinical trial, conducted in the Netherlands, included 252 patients who have been diagnosed with chronic subdural hematoma with computed tomography scan. The severity of these patient’s symptoms were assessed using the Markwalder Grading Scale which has 5 different levels ranging from asymptomatic to comatose. The researchers excluded patients who scored on the two extremes of the Markwalder scale from the study. Patients who were pregnant, had glaucoma, received a cerebrospinal fluid shunt, or were contraindicated for corticosteroids were excluded from the trial due to safety reasons. The average age of the participants was 77 years old and more than half were using antithrombotic medications. These patients were randomly assigned to either receive burr-hole craniostomy within 7 days of diagnosis or dexamethasone. The medication was administered orally or intravenously, in cases which oral administration was not possible. The dexamethasone regimen lasted 19 days with 8 mg every 12 hours for the first 4 days; this dose was decreased by half every 3 days.
The data and safety monitoring board decided to terminate the trial early because of safety concerns for patients in the dexamethasone group. The researchers reported that those who received dexamethasone had a 45% higher odds of experiencing either severe disability or death after 3 months of monitoring. Earlier assessment, after 2 weeks, also showed that patients in the corticosteroid group had a higher odds of disability and a higher score on the Markwalder scale. 59% of those who were treated with dexamethasone also experienced adverse effects and complications, which was higher than the 32% reported by those who received surgery. To be specific, the corticosteroids increase the frequency of pneumonia, hyperglycemia and delirium. As a result, 55% of those in the dexamethasone had to undergo subsequent surgeries.
Previous studies had shown that the anti-inflammatory effect of dexamethasone was beneficial, but these studies were small and did not have a comparison group. A recent study that compared dexamethasone to placebo, also found that the corticosteroids result in worse clinical outcomes. Since, the trial excluded patients who are asymptomatic and comatose, so the effect of dexamethasone on those who have a score of 0 and 4 on the Markwalder scale is unknown. In addition, since the majority of patients who were enrolled in the study had a score of 1 and 2, the trial study can be best applied to patients who are alert or mildly drowsy with slight-to-moderate focal neurologic deficits.
The clinical trial, conducted in the Netherlands, included 252 patients who have been diagnosed with chronic subdural hematoma with computed tomography scan. The severity of these patient’s symptoms were assessed using the Markwalder Grading Scale which has 5 different levels ranging from asymptomatic to comatose. The researchers excluded patients who scored on the two extremes of the Markwalder scale from the study. Patients who were pregnant, had glaucoma, received a cerebrospinal fluid shunt, or were contraindicated for corticosteroids were excluded from the trial due to safety reasons. The average age of the participants was 77 years old and more than half were using antithrombotic medications. These patients were randomly assigned to either receive burr-hole craniostomy within 7 days of diagnosis or dexamethasone. The medication was administered orally or intravenously, in cases which oral administration was not possible. The dexamethasone regimen lasted 19 days with 8 mg every 12 hours for the first 4 days; this dose was decreased by half every 3 days.
The data and safety monitoring board decided to terminate the trial early because of safety concerns for patients in the dexamethasone group. The researchers reported that those who received dexamethasone had a 45% higher odds of experiencing either severe disability or death after 3 months of monitoring. Earlier assessment, after 2 weeks, also showed that patients in the corticosteroid group had a higher odds of disability and a higher score on the Markwalder scale. 59% of those who were treated with dexamethasone also experienced adverse effects and complications, which was higher than the 32% reported by those who received surgery. To be specific, the corticosteroids increase the frequency of pneumonia, hyperglycemia and delirium. As a result, 55% of those in the dexamethasone had to undergo subsequent surgeries.
Previous studies had shown that the anti-inflammatory effect of dexamethasone was beneficial, but these studies were small and did not have a comparison group. A recent study that compared dexamethasone to placebo, also found that the corticosteroids result in worse clinical outcomes. Since, the trial excluded patients who are asymptomatic and comatose, so the effect of dexamethasone on those who have a score of 0 and 4 on the Markwalder scale is unknown. In addition, since the majority of patients who were enrolled in the study had a score of 1 and 2, the trial study can be best applied to patients who are alert or mildly drowsy with slight-to-moderate focal neurologic deficits.