Chronic subdural hematoma: dexamethasone results in worse outcomes vs placebo

  • Hutchinson PJ & al.
  • N Engl J Med
  • 31.12.2020

  • von Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • Among patients with chronic subdural hematoma (SDH), a course of dexamethasone was associated with a lower rate of favorable outcomes and more adverse outcomes.
  • However, placebo was associated in this study with a higher rate of repeat surgery.

Why this matters

  • Chronic SDH incidence is increasing.
  • The condition recurs in up to 1 in 5 surgically treated patients.
  • Few trials have assessed whether dexamethasone is safe or effective.

Key results

  • Dexamethasone vs placebo:
    • Favorable outcome at 6 months:
      • 83.9% vs 90.3%.
      • Difference, −6.4 (95% CI, −11.4 to −1.4 percentage points; P=.01);
      • OR, 0.55 (95% CI, 0.33-0.91) favoring placebo (P=.02).
    • Favorable outcome at 3 months:
      • 83.2% vs 91.4%.
      • Difference, −8.2 (95% CI, −13.3 to −3.1 percentage points). 
    • Repeat surgery: 1.7% vs 7.1%. 
    • Adverse events: OR, 3.4 (95% CI, 1.81-6.85).
    • Serious adverse events: 2.49 (95% CI, 1.54-4.15).

Study design

  • Multicenter, randomized Dex-CSDH trial (n=680).
  • Elderly patients with symptomatic chronic SDH were randomly assigned to a 2-week course of dexamethasone (tapered down from 8 mg twice daily) vs placebo.
  • Outcome: favorable 6-month functional outcome per modified Rankin scale.
  • Funding: National Institute for Health Research, UK.

Limitations

  • Most patients initially underwent surgical evacuation.
  • Unclear whether results would have been different in a more conservatively managed cohort.