Dexamethasone less effective than burr-hole drainage for treating chronic subdural hematoma

1. In this randomized controlled trial, dexamethasone treatment was not noninferior to burr-hole drainage regarding functional outcomes in patients with chronic subdural hematoma.

2. Dexamethasone treatment led to more complications and a greater likelihood of surgery as compared to burr-hole drainage for patients with chronic subdural hematoma.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Chronic subdural hematoma is a condition that has a relatively high prevalence in the geriatric population. Burr-hole craniostomy is often the mainstay of treatment in symptomatic patients, which is a form of surgical evacuation of the hematoma. However, dexamethasone has been proposed as an alternative, nonoperative treatment strategy for chronic subdural hematoma. Yet, there remains a gap in knowledge as to understanding whether dexamethasone without initial surgery has the same potential as surgery alone to achieve favorable outcomes in patients with chronic subdural hematoma. Overall, this study found that dexamethasone was not noninferior to surgery by burr-hole drainage in patients with chronic subdural hematoma. This study was limited by enrolling a small number of patients, the lack of treatment guidelines for chronic subdural hematoma, and differences in local practices at participating centers. Nevertheless, these study’s findings are significant, as they demonstrate that dexamethasone therapy is not noninferior as compared to burr-hole drainage and leads to more complications and adverse events in patients with chronic subdural hematoma.

Click to read the study in NEJM

Relevant Reading: Trial of Dexamethasone for Chronic Subdural Hematoma

In-Depth [randomized controlled trial]: This open-label, randomized controlled trial was conducted at 12 hospitals in the Netherlands. Patients who were 18 years of age or older from the outpatient clinics and emergency departments of participating hospitals who had newly diagnosed symptomatic chronic subdural hematoma detected on computed tomography (CT) were eligible for the study if they had associated symptoms. Patients who had an acute subdural hematoma, were asymptomatic or comatose, had poorly regulated diabetes mellitus, had glaucoma, were pregnant, had received a cerebrospinal fluid shunt, or had contraindications to glucocorticoids were excluded from the study. The primary outcome measured was the functional outcome three months after randomization. Outcomes in the primary analysis were assessed via a proportional odds regression. Based on the primary analysis, the adjusted common odds ratio for a lower (better) score on the modified Rankin scale at three months with dexamethasone than with surgery was 0.55 (95% confidence interval, 0.34 to 0.90), which failed to show noninferiority of dexamethasone. Additionally, complications occurred in 59% of the patients in the dexamethasone group and 32% of those in the surgery group. Further surgery was performed in 55% of patients in the dexamethasone group and 6% of those in the surgery group. This study demonstrates that dexamethasone is not noninferior to the surgical management of chronic subdural hematoma and leads to more significant complications.

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