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

Background: Chronic subdural hematoma is a common neurosurgical condition especially in the aging population.Burr hole for drainage is an effective treatment, yet recurrence is reported at 8 to 22 ％ worldwide, and 1-year mortality rates could be as high as 32 ％.Our previous study on the use of dexamethasone as a primary nonsurgical treatment showed good response in selected group of patients.This study aims to assess the efficacy of dexamethasone with surgical drainage in the reduction of recurrence requiring reoperation.Methods: From October 2000 to September 2006, patients with chronic subdural hematoma admitted to the Prince of Wales Hospital, The Chinese University of Hong Kong, were randomized to surgical drainage with steroid versus surgical drainage only.The primary endpoint was symptomatic recurrence requiring reoperation.Results: Two hundred forty-eight patients were recruited and consented for the randomization during the study period.One hundred twenty-two received both surgery and steroid (the intervention arm) while 126 received surgery only (the control arm).The recurrence rate requiring reoperation was 6.6 ％ (8/122) and 13.5 ％ (17/126),respectively (p =0.109).There was no significant difference in complications such as chest infection (p =0.201) or wound infection (p =0.987).Favorable outcome (Glasgow Outcome Score 4-5) was 104/122 (85.2 ％) in the intervention group versus 105/126 (83.3 ％) in the control group, respectively (p =0.811).Based on the recurrence rate in our study, we generate a potential sample size of at least 594 patients (type Ⅰ error =5 ％, power =80 ％,two-sided test) to detect a significant difference.Conclusions, brief summary, and potential implications: In this prospective pilot phase IIB randomized controlled study, steroid with surgical drainage had a lower recurrence with reoperation though statistically insignificant.It was safe with no significant difference in complication rates.This pilot study generates a potential sample size for a definitive larger double-blinded randomized controlled trial in the future.

ABC/2 formula for"bedside"postoperative pneumocephalus volume measurement

Background:Postoperative pneumocephalus is associated with a higher risk of recurrence of chronic subdural hematoma(cSDH).However,there is no verified simple way to measure the pneumocephalus volume at the bedside for daily clinical use.The ABC/2 method was shown to be a simple and reliable technique to estimate volumes of intracranial lesions,such as intracranial hematomas.This study aims to evaluate the accuracy of the ABC/2 formula in estimating volumes of pneumocephalus,as compared to the gold standard with computer-assisted volumetric analysis.Methods:A total of 141 postoperative computed tomographic(CT)brain scans of cSDH patients with burr-hole drainage were analysed.Pneumocephalus volume was measured independently by both the ABC/2 formula and the computer-assisted volumetric measurement.For the computer-assisted measurement,the volume of the air was semiautomatically segmented and calculated by computer software.Linear regression was used to determine the correlation between the ABC/2 method and computer-assisted measurement.Results:The postoperative pneumocephalus volume after bilateral burr-hole drainage was significantly larger than that of unilateral burr-hole drainage(29.34 ml versus 12.21 ml,p<0.001).The estimated volumes by the formula ABC/2 significantly correlated to the volumes as measured by the computer-assisted volumetric technique,with r=0.992(p<0.001).The Pearson correlation coefficient is very close to 1,which signifies a very strong positive correlation,and it is statistically significant.Conclusions:An excellent correlation is observed between the ABC/2 method and the computer-assisted measurement.This study verified that the ABC/2 method is an accurate and simple"bedside"technique to estimate pneumocephalus volume.

Chronic subdural haematoma during the COVID-19 lockdown period:late presentation with a longer interval from the initial head injury to the final presentation and diagnosis

Background:The COVID-19 novel coronavirus is contagious,and the mortality is higher in the elderly population.Lockdown in different parts of the world has been imposed since January 2020.Chronic subdural haematoma (cSDH) has a unique natural history in which symptoms can be non-specific,and the onset is insidious.This study aims to evaluate the impact of the COVID-19 pandemic on the presentation of cSDH.Methods:Consecutive adult cSDH patients admitted from 1 March 2020 to 30 April 2020 were reviewed.Exclusion criteria including those who had no definite history of head injury or the diagnosis of cSDH were made from a scheduled follow-up scan.Corresponding data during the same period in 2019 were reviewed for comparison.The primary outcome was the interval between the initial head injury and the final radiological diagnosis of cSDH.Secondary outcomes include Markwalder chronic subdural haematoma grade upon admission,length of stay in the acute hospital,and the modified Rankin scale (mRS) upon discharge.Results:For the primary outcome,the average interval between head injury and the diagnosis of cSDH was significantly longer at 56.6 days (49 to 74 days,SD 9.83 days) during the period from March to April 2020,versus 29.4 days (17 to 42 days,SD 8.59 days) in 2019 for the corresponding period (p = 0.00703).There was no significant difference in the functional outcome upon discharge.Conclusions:cSDH patients can present late during the COVID-19 lockdown period.The functional outcome was comparable when operations for drainage were timely performed.