Pharmacological Treatment in the Management of Chronic Subdural Hematoma

Abstract

Background: Several pharmacological treatments have been used to treat patients with chronic subdural hematoma (CSDH), although little is known about the comparative effectiveness of different classes of medication. We performed a Bayesian network meta-analysis to compare and rank the efficacy and safety of five drug regimens to determine the best treatment for this group of patients.Methods: We systematically searched PubMed, Medline, clinicaltrials.gov, the Cochrane database, and Embase to identify relevant randomized clinical trials (RCTs) comparing drug treatments in adult patients with CSDH. A network meta-analysis was conducted using a Bayesian framework. Random- and fixed-effects models were used to pool the network results, and the preferred model was selected by comparing the deviance information criteria (DIC). Efficacy outcomes included recurrence requiring surgery, changes in hematoma volume, and a good recovery. The safety outcomes were treatment-related adverse events and all-cause mortality.Results: In this Bayesian network meta-analysis, available data were obtained from 12 eligible trials, including 2,098 patients and 5 techniques. Compared to placebo, atorvastatin (RR: 0.45, 95% CrI: 0.24–0.81) and dexamethasone (RR: 0.38, 95% CrI: 0.22–0.63) were similarly effective in reducing recurrence requiring surgery by 55% and 62%, respectively. Dexamethasone (RR: 0.46, 95% CrI: 0.23–0.91) was more effective in reducing recurrence requiring surgery than goreisan. Additionally, atorvastatin reduced the hematoma volume to a greater extent than placebo (MD: −7.44, 95% CrI: −9.49 to −5.43) or goreisan (MD: −14.09, 95% CrI: −23.35 to −4.82). Moreover, tranexamic acid (MD: −12.07, 95% CrI: −21.68 to −2.29) reduced the hematoma volume to a greater extent than goreisan. No significant differences were detected between drugs and placebo with regard to a good recovery. In terms of safety, dexamethasone (RR: 1.96, 95% CrI: 1.20–3.28) increased the risk of mortality compared to placebo.Conclusion: These findings suggest that dexamethasone is the best treatment to reduce recurrence and atorvastatin is the best treatment to reduce hematoma volume in patients with CSDH. However, clinicians should pay close attention to the elevated risk of all-cause mortality and potential adverse events caused by dexamethasone. Future well-designed RCTs with more participants are needed to verify these findings.Clinical Trial Registration:http://osf.io/u9hqp.

Role of Adjunctive Tranexamic Acid in Facilitating Resolution of Chronic Subdural Hematoma after Surgery

“…A large cohort study or meta-analysis should be warranted to reveal significant differences. 9,29) Despite this statistical aspect, adjunctive TXA use was expected to be effective in decreasing the recurrence of CSDH because it certainly reduced residual hematoma in time. Several studies universally reported a positive role of TXA in reducing residual CSDH during follow-up period.…”

“…In addition, statins, another potentially beneficial drug in reducing CSDH recurrence, was administered more frequently to the patients in the TXA group. 5,8,22,24,25,29) TXA administration was conducted relatively recently in this cohort, and a more detailed investigation of drug history for the TXA group may be the reason for the imbalance. Although multivariate analysis revealed no relationship between statin administration and study outcomes, combined effects of TXA and statins need to be investigated.…”

Japanese herbal Kampo medicine, Keishibukuryogan, for chronic subdural hematoma – Prospective observational study

“…CSDH recurs from the theories of inflammation, angiogenesis, exudates, recurrent microbleeds, and local coagulopathy, which are shown by pathologically[ 6 , 14 ] and basically. [ 19 ] Therefore, these medications may have effects from these pathophysiological perspectives. Many previous clinical trials of drugs have been performed on CSDH patients after surgery to improve the recurrence rate.…”

“…[ 9 , 12 , 15 ] In addition to devising a surgical technique,[ 1 , 6 ] various medication to prevent postoperative recurrence is reported. [ 19 ]…”

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

“…Therefore, low-dose DXM treatment is always used clinically, and the duration should be no more than 4 weeks, but the application of DXM is still inevitably accompanied by side effects. The research of Wang et al (2021)indicated that DXM increased the risk of all-cause mortality (relative risk (RR) = 1.96, 95% CrI 1.20, 3.28) of CSDH, and the adverse events resulting from DXM treatment were generally serious even with low doses. Additionally, our studies found that the low-dose DXM combined with ATO resulted in the best effectiveness concerning reducing reoperation as compared to any other drug interventions.…”