Effectiveness Comparisons of Drug Therapy on Chronic Subdural Hematoma Recurrence: A Bayesian Network Meta-Analysis and Systematic Review

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).

Predictors of re-operation in the setting of non-acute subdural hematomas: A 12-year single center retrospective study

Non-acute subdural hematomas (naSDH) may recur after surgical treatment. A second operation affects the quality of life and functional outcome of the patients, and lengthens hospital stay. We aim to identify the predictors of reoperation as the healthcare system in the US is moving towards patient-centered care. This retrospective study included patients treated surgically with burr-holes or mini-craniotomy for non-acute subdural hematoma between February 2006-June 2018. Univariate and multiple logistic regression models were performed. 23 (12.0%) patients had reoperation. Controlling for all the factors, postoperative acute blood in the operative bed was the strongest predictor of recurrence of naSDH (OR = 37.93, 95% CI: 5.35-268.87, p < 0.001). Those undergoing a mini-craniotomy were over six times as likely to experience a recurrent SDH compared to those operated on via burr holes (OR = 6.34, 95% CI: 1.21-33.08, p = 0.029). Finally, patients with a past medical history of thrombocytopenia were nearly six times as likely to experience a recurrence of SDH (OR = 5.80, 95% CI: 1.20-28.10, p = 0.029). Postoperative hematoma thickness showed a trend toward significance such that thicker hematomas were associated with an increased likelihood of experiencing a recurrent SDH. In conclusion, we found that operative technique, thrombocytopenia and the presence of postoperative hemorrhage are significant predictors for reoperation. Given the current interest in endovascular embolization for SDH, understanding these risk factors may aid in determining indications for such adjunctive treatment.

Subdural Drain versus Subdural Evacuating Port System for the Treatment of Nonacute Subdural Hematomas: A Single-Center Retrospective Cohort Study

BACKGROUND

Subdural drain (SDD) and Subdural Evacuating Port System (SEPS) are bedside options for management of nonacute subdural hematomas (SDHs). These interventions have not been compared with each other. Our objective is to compare the need for second bedside procedure, need for craniotomy, complication rate, and other outcomes related to bedside drainage of SDH with SDD or SEPS. We hypothesized that SDD would be associated with superior outcomes to SEPS.

METHODS

Database queries and direct patient chart reviews were used to gather patient data. t-Tests, Fisher exact tests, and proportional odds models were performed.

RESULTS

Of 41 SDDs and 25 SEPS, baseline characteristics were similar except more isodense SDHs were present in SDD (P = 0.0312). SEPS was associated with significant risk of requiring a second bedside procedure (odds ratio, 3.2381; 99% confidence interval, 1.0345-10.1355) relative to SDD. Need for craniotomy did not differ between groups (12.1% SDD vs. 16% SEPS; P = 0.721). The complication rate was similar between groups (2.4% SDD vs. 12% SEPS; P = 0.1484). Symptom resolution, condition at latest follow-up, and posthospital disposition were similar between groups, but SEPS was associated with longer intensive care unit and total hospital length of stay (P = 0.02 and 0.04, respectively).

CONCLUSIONS

SEPS was associated with higher risk for need of second bedside procedure and longer intensive care unit and hospital length of stay than SDD, although not increased need for craniotomy. Additional studies are needed to confirm our findings and determine if SDD may be more effective than SEPS for the treatment of nonacute SDH.