Effect of Steroid Therapy on Risk of Subsequent Surgery for Neurologically Stable Chronic Subdural Hemorrhage-Retrospective Cohort Study and Literature Review

Factors associated with success of conservative therapy in chronic subdural hematoma: a single-center retrospective analysis

INTRODUCTION

Conservative therapy is a viable option for patients with chronic subdural hematoma (cSDH) who express no, or only mild symptoms. It is not clear which factors are associated with success of conservative therapy. This study aims to determine conservative therapy's success rate and to identify features possibly associated with success.

METHODS

A monocenter retrospective cohort study, including cSDH patients treated conservatively (wait-and-watch) from 2012 to 2022, was performed. The primary outcome was success of conservative therapy, defined as 'no crossover to surgery' during the follow-up period. Secondary outcomes were (1) factors associated with success, analyzed with univariate and multivariable logistic regression analyses, (2) 30-day mortality (3) time to crossover and (4) reasons for crossover.

RESULTS

We included 159 patients. Conservative therapy was successful in 96 (60%) patients. Hematoma volume (OR 0.79, 95% CI 0.69-0.92) and hypodense hematoma type (OR 3.57, 95% 1.38-9.23) were associated with success. Thirty-day mortality rate was 5% and the median duration between diagnosis and surgery was 19 days (IQR 8-39). Clinical deterioration was the most frequent reason for crossover (in 61/63 patients, 97%) and was accompanied by radiological hematoma progression in 42 patients (67%).

CONCLUSION

In this selected group of patients, conservative therapy was successful in 60%. Smaller hematoma volume and hypodense hematoma type were associated with success. As time until crossover was approximately three weeks, deploying conservative therapy as primary treatment seems safe and could be rewarding as surgical complications can be avoided. Improvement in patient selection in future cohorts remains warranted.

Efficacy and safety of steroids for chronic subdural hematoma: A systematic review and meta-analysis

Background

Chronic subdural hematoma (CSDH) is a condition characterized by the accumulation of fluid, blood, and blood breakdown products between the brain's arachnoid and dura mater coverings. While steroids have been explored as a potential treatment option, their efficacy and safety remain uncertain. This meta-analysis and systematic review aimed to assess the impact of steroids on CSDH management, including mortality, recurrence, complications, and functional outcomes.

Methods

We conducted a comprehensive literature search in major electronic databases up to June 2023, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane Handbook for Systematic Reviews and Interventions. Inclusion criteria encompassed adult patients with CSDH, the use of steroids as monotherapy or adjuvant therapy, and clearly defined outcomes. Randomized controlled trials and cohort studies meeting these criteria were included in the study.

Results

The initial search yielded 4315 articles, with 12 studies meeting the inclusion criteria. Our findings indicate a non-significant trend toward reduced mortality with steroids in combination with standard care (Odds ratios [OR] = 0.66, 95% confidence interval [CI] 0.20-2.18). However, substantial heterogeneity was observed (I2 = 70%). Sensitivity analysis, excluding influential studies, suggested a potential increased mortality risk associated with steroids (OR = 1.47, 95% CI 0.87-2.48). Steroids showed a possible benefit in reducing the recurrence of CSDH (OR = 0.58, 95% CI 0.20-1.67), but with significant heterogeneity (I2 = 89%). No clear advantage of steroids was observed in terms of functional outcomes at three months (modified Rankin scale scores). Furthermore, steroids were associated with a significantly higher incidence of adverse effects and complications (OR = 2.17, 95% CI 1.48-3.17).

Conclusion

Steroids may have a potential role in reducing CSDH recurrence but do not appear to confer significant advantages in terms of mortality or functional outcomes. However, their use is associated with a higher risk of adverse effects and complications. Given the limitations of existing studies, further research is needed to refine the role of steroids in CSDH management, considering patient-specific factors and treatment protocols.

Success of conservative therapy for chronic subdural hematoma patients: a systematic review

Background

Conservative therapy for chronic subdural hematoma (cSDH) is an option for patients who express no, or only mild symptoms, thereby preventing surgery in some. Because it is not clear for whom conservative therapy is successful, we aimed to estimate the success rate of conservative therapy and to identify which factors might influence success.

Methods

We systematically searched MEDLINE and EMBASE databases to identify all available publications reporting outcome of conservative therapy for cSDH patients. Studies containing >10 patients were included. The primary outcome was the success rate of conservative therapy, defined as "no crossover to surgery" during follow-up. In addition, factors possibly associated with success of conservative therapy were explored. Bias assessment was performed with the Newcastle Ottowa Scale and the Cochrane risk-of-bias tool. We calculated pooled incidence and mean estimates, along with their 95% confidence intervals (CIs), using OpenMeta[Analyst] software.

Results

The search yielded 1,570 articles, of which 11 were included in this study, describing 1,019 conservatively treated patients. The pooled success rate of conservative therapy was 66% (95% CI: 50-82%). One study (n = 98) reported smaller hematoma volume to be associated with success, whilst another study (n = 53) reported low hematoma density and absence of paresis at diagnosis to be associated with success.

Conclusion

Conservative therapy is reported to be successful in the majority of cSDH patients who have either no, or only mild symptoms. Hematoma volume, low hematoma density and absence of paresis could be factors associated with success. However, further research is warranted in order to establish factors consistently associated with a successful conservative therapy.

Other

No funding was acquired for this study. The study was not registered nor was a study protocol prepared.

Cerebrospinal fluid leak as a driving factor in chronic subdural hematoma formation: A histological study

Background:

Chronic subdural hematoma (CSDH) represents the most common neurosurgical disease. Given the demographic shift toward an aging population, the overall incidence of this condition is increasing. Nevertheless, clarity in the pathophysiological process is yet to be made. Several etiological mechanisms have been proposed to initiate and consequently promote fluid collection in the subdural space. Traumatic injury of the bridging veins has long been considered the primum movens of the pathology but increasing evidence shows that trauma is not the only factor involved. Along with recent advances we sought to understand the role of the cerebrospinal fluid (CSF) in the buildup of the intense inflammatory reaction that characterizes CSDH.

Methods:

In the present study, we examined histological features of reactive membranes secondary to extracranial CSF leakage with CSDH-related membranes. Similarity and differences between the specimens were examined by means of light microscopy.

Results:

Histological similarities were consistently found between CSDH membranes and reactive membranes secondary to CSF leakage in the extracranial space. Activated histiocytes were highlighted in all specimens along with an intense inflammatory reaction.

Conclusion:

CSDH is most likely the result of a complex interaction among different pathophysiological events resulting from both traumatic and inflammatory etiologies. In the present work, we highlight how CSF leakage could be an early factor that leads to a cascade of events that culminates in CSDH formation.

Steroid in Chronic Subdural Hematoma: An Updated Systematic Review and Meta-Analysis Post DEX-CSDH Trial

BACKGROUND

Chronic subdural hematoma (CSDH) is a neurologic condition characterized as a hematoma in the subdural space with a period >3 weeks that primarily affects the elderly. Glucocorticoid, especially dexamethasone, either alone or combined with surgery, has been used to manage CSDH. We aimed to perform an updated systematic review and meta-analysis of the literature regarding the role of steroids in CSDH.

METHODS

We searched the electronic databases PubMed, PubMed Central, Scopus, and Embase for relevant articles until December 2020. Study characteristics, quality, and end points were extracted, and analysis was performed by RevMan 5.4.

RESULTS

The odds for subdural hematoma recurrence were decreased by 61% in the steroid group (odds ratio [OR], 0.39; confidence interval [CI], 0.19-0.79) compared with the control group. There was no significant difference in mortality during the study period (OR, 0.66; CI, 0.20-2.18), modified Rankin Scale score 0-3 (OR, 0.87; CI, 0.31-2.40), and modified Rankin Scale score 4-6 (OR, 1.15; CI, 0.42-3.18) between the 2 groups. However, pooling data from 3 studies showed 2.7 times higher odds of occurring adverse effects in steroid groups using the fixed-effect model (OR, 2.70; CI, 1.71-4.28). The treatment success was similar between the steroid and control groups (OR, 2.39; CI, 0.94-6.04).

CONCLUSIONS

Treatment with steroids was associated with a lesser recurrence of CSDH. However, there was no benefit of steroid treatment in CSDH compared with nonsteroid treatment in terms of mortality and treatment success and some but significantly increased risk of adverse events.

Calvarium Subperiosteal Hematoma in a 12-Year-Old Boy

Calvarium subperiosteal hematoma (C-SPOH) is extremely rare in juveniles. We present an extremely rare case of juvenile C-SPOH and a review of the literature. A 12-year-old boy hit his head hard against another player’s head during a soccer game. On the next day of the game (Day 02), he noticed a soft bump on the left parietal region. On Day 04, he saw a local physician and was diagnosed with a subgaleal hematoma. The hematoma grew larger, up to twice the size of that on Day 04 and it became more painful over the next five days. A CT scan on Day 10 showed a subcutaneous hematoma that did not cross the suture lines. Aspiration using a syringe with an 18-gauge needle obtained about 45 mL liquefied hematoma and caused the bump collapse with relief of the pain. On Day 12, however, he presented the same bump with similar pains as on Day 10. CT angiography revealed no vascular anomalies or disruptions. A blood sampling test demonstrated normal blood coagulation ability without thrombocytopenia or malnutrition. A second aspiration obtained 45 mL liquefied hematoma. In the second procedure, the hematoma cavity was irrigated with normal saline solution (about 5 mL x 4). He took 250 mg tranexamic acid three times a day and 5 mg prednisolone three times a day for four days. On Day 15, his C-SPOH was not tense and not painful. On Day 22, the periosteal hematoma remained soft and shrunk. A follow-up CT scan showed the complete disappearance of the subperiosteal hematoma on Day 57. The boy has returned to soccer-playing activity without sequelae. This case suggests that 1) C-SPOH can be found in healthy juveniles; 2) Neovascularization along the wall of the C-SPOH cavity may contribute to the formation of the C-SPOH; 3) A simple aspiration of the liquefied SPOH may fail to cure it in juveniles.

Hematoma subdural crónico: Una patología común de manejo complejo

Antecedentes:

El hematoma subdural crónico (HSDC) es una patología ampliamente estudiada, muy frecuente, sobre todo en adultos mayores; su cuadro clínico tiene una apariencia benigna y suele ir acompañado de múltiples comorbilidades asociadas a la edad, lo que resulta en un aumento de las complicaciones e incluso la muerte. Con el incremento de la expectativa de vida a nivel mundial, el uso de medicamentos antitrombóticos es cada vez más frecuente. El papel de estos fármacos en la evolución de la enfermedad como en la recurrencia, sigue siendo motivo de discusión.

Métodos:

Los autores revisaron la fisiopatología y características clínicas del HSDC. El presente artículo discute acerca de las terapéuticas actuales y las nuevas opciones de tratamiento que podrían mejorar los resultados. Este manuscrito es susceptible de cambios en el tiempo, con el desarrollo científico y tecnológico.

Resultados:

El HSDC puede ser abordado por vía quirúrgica y farmacológica; no obstante, un manejo individualizado requiere la consideracion cuidadosa de diversos factores. A pesar de los avances en el campo de la neurocirugía, la clásica trepanación craneal sigue siendo el Gold estándar en el HSDC y sobre todo en pacientes con síntomas graves. Se debe resaltar que aún hay aspectos de este procedimiento (como la localización del dren, número de drenajes, el efecto de la irrigación, la temperatura de la solución con que se irriga, etc.) que siguen siendo materia de estudio.

Conclusiones:

Entender el mecanismo de la enfermedad ha permitido explicar su historia natural y a su vez proponer nuevas alternativas de tratamiento. El manejo médico (atorvastatina, corticoides) ha generado gran interés por sus alentadores resultados preliminares. Recientemente, se ha reportado la terapia endovascular como una alternativa segura y existe gran expectativa por confirmar su efecto en estudios más grandes.