Advertisement

Corticosteroid treatment compared with surgery in chronic subdural hematoma: a systematic review and meta-analysis

  • Dana C. HollEmail author
  • Victor Volovici
  • Clemens M. F. Dirven
  • Fop van Kooten
  • Ishita P. Miah
  • Korné Jellema
  • Wilco C. Peul
  • Niels A. van der Gaag
  • Kuan H. Kho
  • Heleen M. den Hertog
  • Ruben Dammers
  • Hester F. Lingsma
Review Article - Brain trauma
Part of the following topical collections:
  1. Brain trauma

Abstract

Background

There is an ongoing debate on the role of corticosteroids in the treatment of chronic subdural hematoma (CSDH). This study aims to evaluate the effectiveness of corticosteroids for the treatment of CSDH compared to surgery.

Method

A systematic search was performed in relevant databases up to January 2019 to identify RCTs or observational studies that compared at least two of three treatment modalities: the use of corticosteroids as a monotherapy (C), corticosteroids as an adjunct to surgery (CS), and surgery alone (S). Outcome measures were good neurological outcome, need for reintervention, mortality, and complications. Effect estimates were pooled and presented as relative risk (RR) with 95% confidence interval (95%CI).

Results

Of 796 initially identified studies, 7 were included in the meta-analysis. Risk of bias was generally high. There were no differences in good neurological outcome between treatment modalities. The need for reintervention varied between 4 and 58% in C, 4–12% in CS, and 7–26% in S. The need for reintervention was lower in CS compared with C (RR 3.34 [95% CI 1.53–7.29]; p < 0.01) and lower in CS compared with S (RR 0.44 [95% CI 0.27–0.72]; p < 0.01). Mortality varied between 0 and 4% in C, 0–13% in CS, and 0–44% in S. Mortality was lower in CS compared with S (RR 0.39 [95% CI 0.25–0.63]; p < 0.01). There were no differences in complications between treatment modalities.

Conclusions

This meta-analysis suggests that the addition of corticosteroids to surgery might be effective in the treatment of CSDH. However, the results must be interpreted with caution in light of the serious risk of bias of the included studies. This study stresses the need for large randomized trials to investigate the use of corticosteroids in the management of CSDH.

Keywords

Burr hole Chronic subdural hematoma Corticosteroids Medical management Nonsurgical treatment 

Notes

Acknowledgements

The authors would like to thank Wichor M. Bramer, information specialist at the Erasmus Medical Centre in Rotterdam, The Netherlands, for his assistance in the literature search. The authors are part of the Dutch Chronic Subdural Hematoma Research group (DSHR); which aims to unite Dutch CSDH-researchers.

Funding

The Netherlands Organisation for Health Research and Development (ZonMw project number 843002824) provided financial support in the form of funding. The sponsor had no role in the design or conduct of this research.

Compliance with ethical standards

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

For this type of study formal consent is not required. This article does not contain any studies with human participants performed by any of the authors.

Supplementary material

701_2019_3881_MOESM1_ESM.docx (19 kb)
ESM 1 (DOCX 19 kb)
701_2019_3881_MOESM2_ESM.docx (13 kb)
ESM 2 (DOCX 13 kb)

References

  1. 1.
    Adhiyaman V, Asghar M, Ganeshram KN, Bhowmick BK (2002) Chronic subdural haematoma in the elderly. Postgrad Med J 78:71–75CrossRefGoogle Scholar
  2. 2.
    Adhiyaman V, Chattopadhyay I, Irshad F, Curran D, Abraham S (2017) Increasing incidence of chronic subdural haematoma in the elderly. QJM 110:375–378CrossRefGoogle Scholar
  3. 3.
    Almenawer SA, Farrokhyar F, Hong C, Alhazzani W, Manoranjan B, Yarascavitch B, Arjmand P, Baronia B, Reddy K, Murty N, Singh S (2014) Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients. Ann Surg 259:449–457CrossRefGoogle Scholar
  4. 4.
    Asghar M, Adhiyaman V, Greenway MW, Bhowmick BK, Bates A (2002) Chronic subdural haematoma in the elderly--a North Wales experience. J R Soc Med 95:290–292Google Scholar
  5. 5.
    Aspegren O, Astrand R, Lundgren M, Romner B (2013) Anticoagulation therapy a risk factor for the development of chronic subdural hematoma. Clin Neurol Neurosurg 115:981–984CrossRefGoogle Scholar
  6. 6.
    Baechli H, Nordmann A, Bucher HC, Gratzl O (2004) Demographics and prevalent risk factors of chronic subdural haematoma: results of a large single-center cohort study. Neurosurg Rev 27:263–266CrossRefGoogle Scholar
  7. 7.
    Balser D, Farooq S, Mehmood T, Reyes M, Samadani U (2015) Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg 123:1209–1215CrossRefGoogle Scholar
  8. 8.
    Baschera D, Tosic L, Westermann L, Oberle J, Alfieri A (2018) Treatment standards for chronic subdural hematoma: results from a survey in Austrian, German, and Swiss neurosurgical units. World Neurosurg 116:e983–e995CrossRefGoogle Scholar
  9. 9.
    Bender MB, Christoff N (1974) Nonsurgical treatment of subdural hematomas. Arch Neurol 31Google Scholar
  10. 10.
    Berghauser Pont LM, Dirven CM, Dippel DW, Verweij BH, Dammers R (2012) The role of corticosteroids in the management of chronic subdural hematoma: a systematic review. Eur J Neurol 19:1397–1403CrossRefGoogle Scholar
  11. 11.
    Berghauser Pont LM, Dippel DW, Verweij BH, Dirven CM, Dammers R (2013) Ambivalence among neurologists and neurosurgeons on the treatment of chronic subdural hematoma: a national survey. Acta Neurol Belg 113:55–59CrossRefGoogle Scholar
  12. 12.
    Brotis AG, Gatos C, Fountas KN (2018) Letter to the editor regarding “dexamethasone for chronic subdural haematoma: a systematic review and meta-analysis”. Acta Neurochir 160:2145–2147CrossRefGoogle Scholar
  13. 13.
    Cenic A, Bhandari M, Reddy K (2005) Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci 32:501–506CrossRefGoogle Scholar
  14. 14.
    Chan DYC, Sun TFD, Poon WS (2015) Steroid for chronic subdural hematoma? A prospective phase IIB pilot randomized controlled trial on the use of dexamethasone with surgical drainage for the reduction of recurrence with reoperation. Chin Neurosurg J 1:2CrossRefGoogle Scholar
  15. 15.
    Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A, Galacho-Harriero AM, Fernández-Arconada O (2009) Dexamethasone treatment in chronic subdural haematoma. Neurocirugía 20:346–359CrossRefGoogle Scholar
  16. 16.
    Dran G, Berthier F, Fontaine D, Rasenrarijao D, Paquis P (2007) Efficacité de la corticothérapie dans le traitement adjuvant des hématomes sous-duraux chroniques. Étude rétrospective sur 198 cas. Neurochirurgie 53:477–482CrossRefGoogle Scholar
  17. 17.
    Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ (2017) Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 14:108CrossRefGoogle Scholar
  18. 18.
    Ernestus R, Beldzinski P, Lanfermann H, Klug N (1997) Chronic subdural hematoma: surgical treatment and outcome in 104 patients. Surg Neurol 48:220–225CrossRefGoogle Scholar
  19. 19.
    Foelholm R, Waltimo O (1975) Epidemiology of chronic subdural haematoma. Acta Neurochir 32:247–250CrossRefGoogle Scholar
  20. 20.
    Fountas K, Kotlia P, Panagiotopoulos V, Fotakopoulos G (2019) The outcome after surgical vs nonsurgical treatment of chronic subdural hematoma with dexamethasone. Interdiscip Neurosurg Adv Tech Case Manag 16:70–74Google Scholar
  21. 21.
    Gabarrós A, Acebes JJ, Rodríguez R, Cabiol J, Obarrio LL, Mamov A, Isamat F (2000) Resultados del tratamiento quirúrgico del hematoma subdural crónico. Comparación de dos técnicas: minitrépano y drenaje cerrado continuo versus dos trépanos y drenaj e externo abierto. Neurocirugía 11:377–390CrossRefGoogle Scholar
  22. 22.
    Gelabert-González M, Fernández-Villa JM, López-García E, García-Allut A (2001) Hematoma subdural crónico en el paciente mayor de 80 años. Neurocirugía 12:325–330CrossRefGoogle Scholar
  23. 23.
    Gelabert-Gonzalez M, Iglesias-Pais M, Garcia-Allut A, Martinez-Rumbo R (2005) Chronic subdural haematoma: surgical treatment and outcome in 1000 cases. Clin Neurol Neurosurg 107:223–229CrossRefGoogle Scholar
  24. 24.
    Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JAC (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ:d5928Google Scholar
  25. 25.
    Holl DC, Volovici V, Dirven CMF, Peul WC, van Kooten F, Jellema K, van der Gaag NA, Miah IP, Kho KH, den Hertog HM, Lingsma HF, Dammers R, Dutch Chronic Subdural Hematoma Research G (2018) Pathophysiology and non-surgical treatment of chronic subdural hematoma: from past to present to future. World Neurosurg 116:402–411 e402CrossRefGoogle Scholar
  26. 26.
    Holl DC, Volovici V, Dirven CM, Van Kooten F, Miah IP, Jellema K, Peul WC, Van der Gaag NA, Kho KH, Den Hertog HM, Dammers R, Lingsma HF (2019) PROSPERO record: corticosteroid treatment compared to surgery in chronic subdural hematoma: a systematic review and meta-analysis. https://www.crd.york.ac.uk/prospero. Registration number CRD42019123594; last edited 27/03/2019
  27. 27.
    Jennett B, Bond M (1975) Assessment of outcome after severe brain damage. Lancet 1:480–484CrossRefGoogle Scholar
  28. 28.
    Jung Y, Jung N, Kim E (2015) Independent predictors for recurrence of chronic subdural hematoma. J Korean Neurosurg Soc 57:266–270CrossRefGoogle Scholar
  29. 29.
    Karibe H, Kameyama M, Kawase M, Hirano T, Kawaguchi T, Tominaga T (2011) Epidemiology of chronic subdural hematomas. No Shinkei Geka 39:1149–1153Google Scholar
  30. 30.
    Kirley K, Qato D, Kornfield R, Stafford R, Alexander G (2012) National trends in oral anticoagulant use in the United States, 2007 to 2011. Circ Cardiovasc Qual Outcomes 5:615–621CrossRefGoogle Scholar
  31. 31.
    Ko BS, Lee JK, Seo BR, Moon SJ, Kim JH, Kim SH (2008) Clinical analysis of risk factors related to recurrent chronic subdural hematoma. J Korean Neurosurg Soc 43:11–15CrossRefGoogle Scholar
  32. 32.
    Kudo H, Kuwamura K, Izawa I, Sawa H, Tamaki N (1992) Chronic subdural hematoma in elderly people: present status on Awaji Island and epidemiological prospect. Neurol Med Chir (Tokyo) 32:207–209CrossRefGoogle Scholar
  33. 33.
    Kwon T, Park Y, Lim D et al (2000) Chronic subdural hematoma: evaluation of the clinical significance of postoperative drainage volume. J Neurosurg 93:796–799CrossRefGoogle Scholar
  34. 34.
    Lindvall P, Koskinen L (2009) Anticoagulants and antiplatelet agents and the risk of development and recurrence of chronic subdural haematomas. J Clin Neurosci 16:1287–1290CrossRefGoogle Scholar
  35. 35.
    Markwalder TM, Steinsiepe KF, Rohner M, Reichenbach W, Markwalder H (1981) The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage. J Neurosurg 55:390–396CrossRefGoogle Scholar
  36. 36.
    Mellergard P, Wisten O (1996) Operations and re-operations for chronic subdural haematomas during a 25-year period in a well defined population. Acta Neurochir 138:708–713CrossRefGoogle Scholar
  37. 37.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097CrossRefGoogle Scholar
  38. 38.
    Mori K, Maeda M (2001) Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 41:371–381CrossRefGoogle Scholar
  39. 39.
    Oishi M, Toyama M, Tamatani S, Kitazawa T, Saito M (2001) Clinical factors of recurrent chronic subdural hematoma. Neurol Med Chir (Tokyo) 41:382–386CrossRefGoogle Scholar
  40. 40.
    Pichert G, Henn V (1987) Conservative therapy of chronic subdural hematomas. Schweiz Med Wochenschr 117Google Scholar
  41. 41.
    Prud'homme M, Mathieu F, Marcotte N, Cottin S (2016) A pilot placebo controlled randomized trial of dexamethasone for chronic subdural hematoma. Can J Neurol Sci 43:284–290CrossRefGoogle Scholar
  42. 42.
    Qian Z, Yang D, Sun F, Sun Z (2017) Risk factors for recurrence of chronic subdural hematoma after burr hole surgery: potential protective role of dexamethasone. Br J Neurosurg 31:84–88CrossRefGoogle Scholar
  43. 43.
    Robinson R (1984) Chronic subdural hematoma: surgical management in 133 patients. J Neurosurg 61:263–268CrossRefGoogle Scholar
  44. 44.
    Santarius T, Hutchinson P (2004) Chronic subdural haematoma: time to rationalize treatment? Br J Neurosurg 18:328–332CrossRefGoogle Scholar
  45. 45.
    Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ (2008) The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg 22:529–534CrossRefGoogle Scholar
  46. 46.
    Sterne JAC, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I, Carpenter JR, Chan AW, Churchill R, Deeks JJ, Hrobjartsson A, Kirkham J, Juni P, Loke YK, Pigott TD, Ramsay CR, Regidor D, Rothstein HR, Sandhu L, Santaguida PL, Schunemann HJ, Shea B, Shrier I, Tugwell P, Turner L, Valentine JC, Waddington H, Waters E, Wells GA, Whiting PF, Higgins JPT (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919CrossRefGoogle Scholar
  47. 47.
    Sun TF, Boet R, Poon WS (2005) Non-surgical primary treatment of chronic subdural haematoma: preliminary results of using dexamethasone. Br J Neurosurg 19:327–333CrossRefGoogle Scholar
  48. 48.
    Thotakura AK, Marabathina NR (2015) Nonsurgical treatment of chronic subdural hematoma with steroids. World Neurosurg 84:1968–1972CrossRefGoogle Scholar
  49. 49.
    Torihashi K, Sadamasa N, Yoshida K et al (2008) Independent predictors for recurrence of chronic subdural hematoma: a review of 343 consecutive surgical cases. Neurosurgery 63:1125–1129CrossRefGoogle Scholar
  50. 50.
    Turgut M, Akhaddar A (2017) Dexamethasone for chronic subdural hematoma: a systematic review and meta-analysis. Acta Neurochir 159:2289–2290CrossRefGoogle Scholar
  51. 51.
    Vasella F, Akeret K, Smoll NR, Germans MR, Jehli E, Bozinov O, Regli L, Stienen MN, group CSs (2018) Improving the aesthetic outcome with burr hole cover placement in chronic subdural hematoma evacuation-a retrospective pilot study. Acta Neurochir 160:2129–2135CrossRefGoogle Scholar
  52. 52.
    Victoratos G, Bligh A (1981) A more systematic management of subdural hematoma with the aid of CT scan. Surg Neurol 15:158–160CrossRefGoogle Scholar
  53. 53.
    Voelker JL (2000) Nonoperative treatment of chronic subdural hematoma. Neurosurg Clin N Am 11:507–513CrossRefGoogle Scholar
  54. 54.
    Yao Z, You C (2017) Reply to letter: “dexamethasone for chronic subdural haematoma: a systematic review and meta-analysis”. Acta Neurochir 159:2291CrossRefGoogle Scholar
  55. 55.
    Yao Z, Hu X, Ma L, You C (2017) Dexamethasone for chronic subdural haematoma: a systematic review and meta-analysis. Acta Neurochir 159:2037–2044CrossRefGoogle Scholar
  56. 56.
    Zhang Y, Chen S, Xiao Y, Tang W (2017) Effects of dexamethasone in the treatment of recurrent chronic subdural hematoma. World Neurosurg 105:115–121CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Dana C. Holl
    • 1
    Email author
  • Victor Volovici
    • 1
    • 2
  • Clemens M. F. Dirven
    • 1
  • Fop van Kooten
    • 3
  • Ishita P. Miah
    • 4
  • Korné Jellema
    • 4
  • Wilco C. Peul
    • 5
  • Niels A. van der Gaag
    • 5
    • 6
  • Kuan H. Kho
    • 7
  • Heleen M. den Hertog
    • 8
  • Ruben Dammers
    • 1
  • Hester F. Lingsma
    • 2
  1. 1.Department of Neurosurgery, Erasmus MC Stroke CentreErasmus Medical CentreRotterdamThe Netherlands
  2. 2.Department of Public Health and Medical Decision MakingErasmus MCRotterdamThe Netherlands
  3. 3.Department of Neurology, Erasmus MC Stroke CentreErasmus Medical CentreRotterdamThe Netherlands
  4. 4.Department of NeurologyHaaglanden Medical CentreThe HagueThe Netherlands
  5. 5.Department of NeurosurgeryLeiden University Medical CentreLeidenThe Netherlands
  6. 6.Haaglanden MC and Haga Teaching HospitalThe HagueThe Netherlands
  7. 7.Department of NeurosurgeryMedisch Spectrum TwenteEnschedeThe Netherlands
  8. 8.Department of NeurologyIsala Hospital ZwolleZwolleThe Netherlands

Personalised recommendations