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Vychopen M, Güresir E, Wach J. Anti-Inflammatory Drug Therapy in Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis of Prospective Randomized, Double-Blind and Placebo-Controlled Trials. Int J Mol Sci 2022; 23:ijms232416198. [PMID: 36555838 PMCID: PMC9784956 DOI: 10.3390/ijms232416198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
Althoughanti-inflammatory drug therapy has been identified as potentially beneficial for patients suffering from chronic subdural hematoma (cSDH), contemporary literature presents contradictory results. In this meta-analysis, we aimed to investigate the impact of anti-inflammatory drug therapy on mortality and outcome. We searched for eligible randomized, placebo-controlled prospective trials (RTCs) on PubMed, Embase and Medline until July 2022. From 97 initially identified articles, five RTCs met the criteria and were included in our meta-analysis. Our results illustrate significantly lower rates of recurrent cSDH (OR: 0.35; 95% CI: 0.21-0.58, p = 0.0001) in patients undergoing anti-inflammatory therapy. In the subgroup of patients undergoing primary conservative treatment, anti-inflammatory therapy was associated with lower rates of "switch to surgery" cases (OR: 0.30; 95% CI: 0.14-0.63, p = 0.002). Despite these findings, anti-inflammatory drugs seemed to be associated with higher mortality rates in patients undergoing surgery (OR: 1.76; 95% CI: 1.03-3.01, p = 0.04), although in the case of primary conservative treatment, no effect on mortality has been observed (OR: 2.45; 95% CI: 0.35-17.15, p = 0.37). Further multicentric prospective randomized trials are needed to evaluate anti-inflammatory drugs as potentially suitable therapy for asymptomatic patients with cSDH to avoid the necessity of surgical hematoma evacuation on what are predominantly elderly, vulnerable, patients.
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Yu W, Chen W, Jiang Y, Ma M, Zhang W, Zhang X, Cheng Y. Effectiveness Comparisons of Drug Therapy on Chronic Subdural Hematoma Recurrence: A Bayesian Network Meta-Analysis and Systematic Review. Front Pharmacol 2022; 13:845386. [PMID: 35401183 PMCID: PMC8993499 DOI: 10.3389/fphar.2022.845386] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/07/2022] [Indexed: 12/20/2022] Open
Abstract
Objectives: We aim to compare the effectiveness of different drug treatments in improving recurrence in patients with chronic subdural hematoma (CSDH). Methods: Eligible randomized controlled trials (RCTs) and prospective trials were searched in PubMed, Cochrane Library, and Embase, from database inception to December 2021. After the available studies following inclusion and exclusion criteria were screened, the main outcome measures were strictly extracted. Taking the random-effects model, dichotomous data were determined and extracted by odds ratio (OR) with 95% credible interval (CrI), and a surface under the cumulative ranking curve (SUCRA) was generated to calculate the ranking probability of comparative effectiveness among each drug intervention. Moreover, we used the node-splitting model to evaluate inconsistency between direct and indirect comparisons of our network meta-analysis (NMA). Funnel plots were used to evaluate publication bias. Results: From the 318 articles found during initial citation screening, 11 RCTs and 3 prospective trials (n = 3,456 participants) were ultimately included in our study. Our NMA results illustrated that atorvastatin + dexamethasone (ATO+DXM) (OR = 0.06, 95% CrI 0.01, 0.89) was the most effective intervention to improve recurrence in patients with CSDH (SUCRA = 89.40%, 95% CrI 0.29, 1.00). Four drug interventions [ATO+DXM (OR = 0.06, 95% CrI 0.01, 0.89), DXM (OR = 0.18, 95% CrI 0.07, 0.41), tranexamic acid (TXA) (OR = 0.26, 95% CrI 0.07, 0.41), and ATO (OR = 0.41, 95% CrI 0.12, 0.90)] achieved statistical significance in improving recurrence in CSDH patients compared with the placebo (PLB) or standard neurosurgical treatment (SNT) group. Conclusion: Our NMA showed that ATO+DXM, DXM, ATO, and TXA had definite efficacy in improving recurrence in CSDH patients. Among them, ATO+DXM is the best intervention for improving recurrence in patients with CSDH in this particular population. Multicenter rigorous designed prospective randomized trials are still needed to evaluate the role of various drug interventions in improving neurological function or outcome. Systematic Review Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299491), identifier (CRD 42022299491).
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Affiliation(s)
| | | | | | | | | | | | - Yuan Cheng
- *Correspondence: Xiaolin Zhang, ; Yuan Cheng,
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Zhang J. Expert consensus on drug treatment of chronic subdural hematoma. Chin Neurosurg J 2021; 7:47. [PMID: 34809712 PMCID: PMC8607705 DOI: 10.1186/s41016-021-00263-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is a chronic space-occupying lesion formed by blood accumulation between arachnoid and dura mater, which is usually formed in the third week after traumatic brain injury. Surgical treatment is usually the first choice for patients with CSDH having a significant space-occupying effect. Most of the patients showed good results of surgical treatment, but still some patients had a postoperative recurrence (the recurrence rate was up to 33%). Because CSDH is often seen in the elderly, patients are weak and have many basic diseases. The risk of surgical treatment is high; serious complications and even death (the death rate is up to 32%) can often occur. The overall good prognosis rate of patients aged more than 90 years is 24%. The drug treatment can provide a safe and effective treatment for elderly patients who are weak, intolerable to surgery, or failed in surgery. Low-dose and long-term use of atorvastatin (20mg/d) is suggested for continuous treatment for at least 8 weeks, while low-dose and short-term use of dexamethasone can improve the therapeutic effect of atorvastatin on CSDH. Patients should undergo CT or MRI scanning at least one time within 2 weeks after the start of drug treatment.
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Affiliation(s)
- Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, China. .,Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, 300052, China. .,Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, 300052, China. .,Tianjin Neurological Institute, Tianjin, 300052, China.
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Gong Z, Zhan D, Nie M, Li X, Gao C, Liu X, Xiang T, Yuan J, Jiang W, Huang J, Quan W, Wang D, Tian Y, Yuan H, Zhang J, Jiang R. Dexamethasone enhances the efficacy of atorvastatin in inhibiting excessively inflammation-induced abnormal angiogenesis by regulating macrophages. J Neuroinflammation 2021; 18:203. [PMID: 34526068 PMCID: PMC8444603 DOI: 10.1186/s12974-021-02257-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We have recently showed that atorvastatin (ATO) combined with low dose of dexamethasone (DEX) was more efficacious in treating patients with chronic subdural haematoma (CSDH) than ATO monotherapy. This study was designed to investigate the underlying mechanisms of the improved efficacy of this combined therapy. METHODS Mass spectrometry was performed to quantitatively detect drugs in haematoma fluids and serum samples from CSDH patients and also in cultured macrophages after treatment with either ATO alone or in combination with DEX. The differentiation and apoptosis of macrophages were evaluated using flow cytometry. The expression of cytokines, chemokines and angiogenesis-related proteins was evaluated using proteome profile arrays, immunoblots and ELISA, respectively. RESULTS ATO was detected in haematoma fluids and serum samples, whose levels were increased significantly in samples collected from patients treated with both ATO and DEX. ATO was also increased in cultured macrophages treated with ATO and DEX. The numbers of M1-polarized macrophages were higher than the M2 phenotype in the haematoma fluids of patients. Cultured macrophages treated with ATO and DEX had reduced numbers of M1-polarized macrophages, increased numbers of M2-polarized macrophages as compared to monotherapies, and decreased rate of apoptosis induced by high-dose DEX. DEX enhanced the anti-inflammatory and anti-angiogenic activity of ATO by suppressing VEGFA and other inflammatory angiogenic factors. Consistent with the finding, patients responded well to the drug treatments had lower serum levels of VEGFA. CONCLUSIONS We have shown for the first time that ATO given orally was detected in CSDH haematoma fluids. DEX enhances the anti-inflammatory and anti-angiogenic effects of ATO, primarily by increasing the presence of ATO in haematoma and macrophages and by regulating the functions of macrophages.
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Affiliation(s)
- Zhitao Gong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.,Department of Rehabilitation Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Daqiang Zhan
- Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,Department of pharmacy, Second Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xiaochun Li
- Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.,Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Weiwei Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Hengjie Yuan
- Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China. .,Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China. .,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China. .,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.
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Huang J, Gao C, Dong J, Zhang J, Jiang R. Drug treatment of chronic subdural hematoma. Expert Opin Pharmacother 2020; 21:435-444. [PMID: 31957506 DOI: 10.1080/14656566.2020.1713095] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jingfei Dong
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
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Knopman J, Link TW, Navi BB, Murthy SB, Merkler AE, Kamel H. Rates of Repeated Operation for Isolated Subdural Hematoma Among Older Adults. JAMA Netw Open 2018; 1:e183737. [PMID: 30646255 PMCID: PMC6324600 DOI: 10.1001/jamanetworkopen.2018.3737] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Elderly patients who undergo surgery for an isolated nontraumatic subdural hematoma (SDH) are at major risk for SDH reaccumulation, which can cause further injury and disability. Few population-based studies have examined how often nontraumatic SDH reaccumulates and necessitates repeated operation. OBJECTIVE To determine the rate of repeated operation after evacuation of nontraumatic SDH. DESIGN, SETTING, AND PARTICIPANTS In a cohort study, 2 parallel analyses were performed using data from the National Surgical Quality Improvement Project (NSQIP) from January 1, 2012, through December 31, 2015, and inpatient and outpatient claims data from a 5% nationally representative sample of Medicare beneficiaries from January 1, 2009, to September 30, 2015. In both samples, our cohort comprised patients 65 years or older who underwent surgical evacuation of nontraumatic SDH. Data were analyzed from March 28 to April 13, 2018. MAIN OUTCOMES AND MEASURES The outcome variable was repeated operation for SDH after the index operation. Survival analysis and Kaplan-Meier statistics were used to calculate cumulative rates. RESULTS Among 2 831 274 cases submitted to the NSQIP registry, 515 patients 65 years or older (mean [SD] age, 76.9 [7.4] years; 177 [34.4%] women; 367 [71.3%] white) who underwent craniotomy or craniectomy for nontraumatic SDH were identified. Within 30 days after the index surgery, 37 patients underwent a repeated operation for SDH. The cumulative 30-day mortality rate was 13.8% (95% CI, 11.0%-17.1%), and the repeated operation rate was 7.8% (95% CI, 5.7%-10.7%). Among a cohort of 1 952 305 Medicare beneficiaries, 1534 patients (mean [SD] age, 77.7 [7.0] years; 498 [32.5%] women; 1244 [81.1%] white) who underwent evacuation of nontraumatic SDH were identified. A total of 103 patients underwent a repeated operation within 90 days. The cumulative 30-day mortality rate was 11.6% (95% CI, 10.1%-13.3%), and the repeated operation rate was 4.9% (95% CI, 3.9%-6.2%); the cumulative 90-day mortality rate was 17.6% (95% CI, 15.7%-19.6%), and the repeated operation rate was 7.5% (95% CI, 6.2%-9.0%). The study found no evidence of a significant difference in cumulative repeated operation rates at 90 days between patients whose index surgery was a burr-hole procedure for chronic SDH (11.7%; 95% CI, 6.3%-21.3%) vs a craniotomy or craniectomy (7.2%; 95% CI, 6.0%-8.8%) (P = .14 by the log-rank test). CONCLUSIONS AND RELEVANCE In 2 large cohorts of US patients, approximately 5% to 10% of patients who underwent surgery for nontraumatic SDH were required to undergo repeated operation within 30 to 90 days. These results may inform the design of future prospective studies and trials and help practitioners calibrate their index of suspicion to ensure that patients are referred for timely surgical care.
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Affiliation(s)
- Jared Knopman
- Department of Neurosurgery, Weill Cornell Medical College, New York, New York
| | - Thomas W. Link
- Department of Neurosurgery, Weill Cornell Medical College, New York, New York
| | - Babak B. Navi
- Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Santosh B. Murthy
- Department of Neurology, Weill Cornell Medical College, New York, New York
| | | | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, New York
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Abstract
PURPOSE OF REVIEW Subdural hematomas (SDH) represent common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates. SDH incidence increases with age; numbers of patients affected by SDH continue to rise with our aging population and increasing number of people taking antiplatelet agents or anticoagulation. Medical and surgical SDH management remains a subject of investigation. RECENT FINDINGS Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg, followed by rapid sequence intubation if necessary, and expedited acquisition of imaging to identify a space-occupying lesion. Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging. Medical SDH care focuses on (a) management of intracranial hypertension; (b) maintenance of adequate cerebral perfusion; (c) seizure prevention and treatment; (d) maintenance of normothermia, eucarbia, euglycemia, and euvolemia; and (e) early initiation of enteral feeding, mobilization, and physical therapy. Post-operatively, SDH patients require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness. Here, we review various aspects of medical management with a brief overview of pertinent literature and clinical trials for patients diagnosed with SDH.
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