Nonsurgical Treatment of Chronic Subdural Hematoma with Steroids.Some studies demonstrated the role of steroids in medical management non surgical treatment of chronic subdural hematoma with steroids chronic subdural hematoma CSDH. Aim of our study is to evaluate the role of tfeatment in medical treatment of CSDH and to evaluate the subgroup of patients who respond to steroids. This prospective case study was done for 26 months from Subdkral to May On admission, the parenteral steroid dexamethasone 4 mg was given every 8 hours for 72 hours. If the patient improved, the oral tapering doses of steroids were continued for 1 month. Neurological assessment and computed tomography scan done after 6 weeks. If the patient had not improved at 72 hours, a standard burr hole and evacuation was done.
Nonsurgical Treatment of Chronic Subdural Hematoma with Steroids - ScienceDirect
Chronic subdural haematoma cSDH , one of the most common neurosurgical entities, occurs typically in elderly patients. The incidence is expected to double by the year , owing to the continuous aging of the population. Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations. We provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH.
Of articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series.
However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not type C recommendation. In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery type C recommendation. Tranexamic acid proved effective in a small patient series type C recommendation , but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear.
Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality type C recommendation. However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist type C recommendation , since they seem to promote resolution of the haematoma, especially in patients with hygromas or low-density haematomas on computed tomography.
Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients type C recommendation.
In conclusion, our knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treatment of cSDH.
Chronic subdural haematoma cSDH is a common neurosurgical entity, often caused by head trauma and occurring mostly in elderly patients. Since the incidence is expected to double by the year , owing to the continuous aging of the population, there is a need for evidence-based management guidelines for both general and specialised healthcare practitioners [ 3 ].
Even though the outcome of surgical treatment is considered good, conservative treatment may be highly valuable in some situations. An understanding of the pathophysiology is crucial for the development of medical agents in order to treat cSDHs conservatively. In healthy individuals, the subdural space is a virtual space [ 3 ]. A layer of dural border cells with enlarged extracellular space containing bridging veins is tethered between the dura mater and the arachnoid mater [ 4 ].
In individuals with brain atrophy e. These stretched veins can be easily torn, typically as a result of minor trauma, leading to acute bleeding into the virtual subdural space. Thereafter, fibrin deposition and fibrinolytic organisation occurs, and the blood in the subdural space triggers inflammation [ 5 — 8 ].
After weeks, neomembrane with fragile neocapillaries is formed, typically leading to further microbleeding and the maintenance or enlargement of the SDH. Other factors influencing the enlargement of the SDH are: Chronic SDH is also described as a circumscribed chronic self-perpetuating inflammatory disorder. The contact between cSDH fluid and the dural border cells seems to evoke a local aseptic inflammatory and inflammation-induced angiogenic reaction [ 16 ].
This angiogenic reaction leads to the formation of neomembranes that cause repeated microbleeds into the haematoma cavity. Consequently, cSDH may be considered as an angiogenic disease, where inflammatory phenomena play a major role [ 5 ].
A clinical classification, namely the Markwalder grading score MGS [ 17 ], might help to decide which therapy modality might be more appropriate. However, no consensus exists about the best treatment for each grade and the treatment modality that should be chosen individually for each patient. Symptomatic patients with a confirmed radiological appearance of a haematoma are usually treated surgically, whereas patients with asymptomatic haematomas and small non-space-occupying haematomas can be managed conservatively with a medical agent or through careful observation [ 18 ].
We provide a systematic review summarising the conservative treatment modalities of cSDH and their indications. The emphasis was on studies investigating stand-alone pharmacological treatment of cSDH; if for a specific agent none was available, adjunct treatment to surgery is described. References for this review were identified by searching PubMed from up to and including Abstracts were independently reviewed by two of the authors JS and FN , duplicates were removed and the final list of references was generated fig.
Recommendations type A, B or C were formulated according to the levels of evidence I, II, or III, type A reflecting a high degree of clinical certainty, type B moderate certainty, and type C recommendations meaning either a lack of certainty or even harmfulness. Classification of evidence adapted from Soleman et al. After searching for all terms, records were identified by the database and 1 additional record was identified through other sources.
After removal of 18 duplicates, records were screened. Based on title or abstract review, 84 records were excluded. Out of the remaining records, 93 were excluded with reason, resulting in 35 articles fig. The surgical drainage of a symptomatic cSDH is still considered the preferred treatment.
In general, three primary surgical techniques are used: Twist drill and burr hole craniostomy are suggested for primary treatment with or without symptoms; twist drill craniostomy is used especially in patients with multiple comorbidities [ 3 , 4 ]. Craniotomy permits a good exposure to the brain and is the most effective technique to manage complicated cases [ 3 ].
Class I evidence studies are practically nonexistent and there are still many debates about the surgical treatment of cSDH [ 22 ]. From the literature, it is apparent that conservative therapy for cSDH could be used in some cases.
Conservative management is reserved for asymptomatic small-sized haematomas, patients refusing operation, or those with high operative risk [ 3 , 23 ]. Two surveys among neurosurgeons showed that conservative management is rarely used and therefore more evidence-based prospective studies are needed to evaluate its value and efficacy in patients with cSDH [ 26 , 27 ].
The natural history of cSDH remains unclear. A few small case series and several case reports describe spontaneous resolution of traumatic and nontraumatic cSDHs, even in patients under antiplatelet therapy [ 24 , 28 — 31 ].
Clear indications for a wait and watch or wait and scan regimen do not exist. According to Lee et al. Any force to shrink the brain can be the precipitating factor for the progression of cSDH; the opposite, namely an expansion, leads to spontaneous resolution of the haematoma [ 32 ]. In addition, the interaction between the premorbid status, the maturation of neomembranes, and the dynamics of absorption and expansion influence the progression or regression of SDHs [ 32 ].
Unfortunately, there are no clear clinical or radiological signs that indicate whether the cSDH will resolve spontaneously or not. Some authors advocate that patients who have minimal neurological deficits and lesions of small size with low or isodensity and ventricular dilatation on computed tomography CT have a greater chance for spontaneous resolution of their haematoma [ 33 ]. Others postulate that for patients with mild symptoms and frontal haematomas [ 34 ], or for patients older than 70 years with worsening mental function and brain atrophy, a wait and scan regimen should be followed [ 29 ].
However these conclusions are based on case reports or very small case series type C recommendation. To conclude, wait and watch or wait and scan management is indicated in patients with no or minor symptoms Markwald score 0—1 , or in patients with a premorbid condition not allowing surgical evacuation of cSDH type C recommendation. Corticosteroids inhibit the synthesis of various proinflammatory mediators, immune system cells, proinflammatory enzymes, and the synthesis of nitric oxid and cyclooxygenase.
Vascular endothelial growth factor VEGF , a potent inducer of vascular permeability, was shown to be suppressed by corticosteroids [ 8 ]. In addition, corticosteroids stimulate inflammatory inhibitors like lipocortin, which blocks phospholipase A 2 and ACE [ 35 ].
Therefore, it is postulated that corticosteroids reduce or even disrupt the inflammation-induced angiogenic reaction in cSDH through the inhibition of these inflammatory and angiogenetic factors [ 3 ]. This theory is supported by a study in which cSDH was induced in rats and thereafter treated with corticosteroids. The group of rats treated with intramuscular injection of dexamethasone showed histologically no formation of neomembranes, in contrast to the untreated group where neomembranes were present [ 7 ].
The first study evaluating the nonsurgical treatment of cSDH with corticosteroids was performed in by Bender et al. Of the 75 patients treated medically, 22 were considered as medical failure and therefore underwent operation. The medically treated group showed no mortality and poor outcome in 2 cases, whereas in the surgical group 12 patients died and 7 had poor outcome.
Based on these results the authors recommend surgery as the first choice of treatment in comatose or progressively worsening patients, whereas treatment with corticosteroids should be started in all other patients and when the response is good, should remain the only treatment type C recommendation.
A retrospective study by Pichert et al. They concluded that conservative treatment with corticosteroids can be recommended in patients without distinct focal symptoms and nonsoporose or noncomatose patients type C recommendation.
In , a prospective cohort study of patients with cSDH was conducted, in which 26 patients were treated with corticosteroids dexamethasone 4 mg four times a day for 21 days , 69 patients were treated with burr hole drainage and postoperative corticosteroids, 13 patients had with surgical drainage alone, and 4 patients received neither surgery nor corticosteroids [ 38 ].
In the group without any treatment, two out of four patients ultimately required surgical drainage. Hospitalisation time, outcome and mortality were comparable in the steroid group, the steroid plus surgical drainage group, and the surgical drainage only group. Significant steroid-related complications were not reported, and two diabetic patients treated with steroids required additional insulin therapy for optimal diabetic control only during the treatment period.
The authors conclude that corticosteroids might be a valid alternative for patients with cSDH not suitable for surgical drainage.
However, large randomised studies are needed to confirm these suggestions type C recommendation. The median hospital stay was shorter in the dexamethasone group 6 vs 8 days. In two thirds of the patients treated conservatively surgery was avoided.
A meta-analysis by Almenaver et al. The authors commented, however, that these findings should be interpreted cautiously since the number of studies included was small and further studies are warranted.
Lastly, a recent prospective study evaluated the role of corticosteroids dexamethasone 4 mg every 8 hours for 3 days, if successful dose tapering for 4 weeks as a medical treatment for cSDH in 26 patients [ 40 ]. In 15 cases 10 patients after 3 days, 5 patients at 3—6 weeks burr-hole drainage was eventually needed, whereas the remaining 11 patients were completely relieved of symptoms and showed near total or total resolution of the cSDH on CT after 6—8 weeks.
Two patients developed steroid-related complications. Gender, midline shift, thickness of haematoma and Hounsfield units of the haematoma on CT showed statistically significant differences when the failure group was compared with the success group. The authors then proposed a radiological grading scale table 2 that can help predict the chance of successful treatment with corticosteroids.
They conclude that in patients with low grades 0—2 corticosteroid treatment might be more successful than in high grades 4 and 5 [ 40 ]. A pilot randomised controlled trial recently initiated in Canada enrolled 10 patients treated with steroids dexamethasone 4 mg three times a day for 3 weeks with tapering for a week and 10 patients who received placebo.
Table 3 summarises the studies evaluating corticosteroids as a medical treatment modality for cSDH. In addition, multiple case reports have been published suggesting corticosteroids for the treatment of cSDH [ 42 ].
Proposed radiological grading system of cSDH for evaluating the success of corticosteroid treatment adapted from Thotakura et al. Studies evaluating the treatment of cSDH with corticosteroids: Corticosteroids as an adjuvant treatment to surgical drainage of cSDH have been explored in one meta-anlysis [ 39 ] and a few observational studies [ 27 , 43 — 45 ].