The effectiveness of dexamethasone as an adjunct to surgery on satisfactory resolution of chronic subdural haematomas: a randomised control trial

Background: Chronic subdural haematomas (CSDH) are a commonly encountered neurosurgical problem with no consensus on the optimal treatment strategy. The successful treatment of CSDH remains a major problem with only 64-89% having complete neurological resolution with surgery alone and up to 26% of patients developing persistent bleeding requiring further surgery. The use of corticosteroids as an adjunct to surgery in CSDH may improve outcomes. The evidence for this is unclear and practice is divided among neurosurgeons worldwide. Objective: To compare the incidence of satisfactory resolution between patients with chronic subdural haematoma undergoing surgery who received dexamethasone pre and postoperatively for 6 weeks versus patients who received a placebo for the same period. Study Design: Multi-centre, double blind randomized placebo-controlled trial. Setting: The Aga Khan University Hospital, Nairobi and The Nairobi Hospital. Methods: Fifty-three patients undergoing burrhole surgery for chronic subdural haematoma were randomized into 2 groups (control and intervention group) using a computer-generated table of numbers. Results: The two groups had similar baseline characteristics in terms of age, gender, location of haematoma, initial Glasgow Coma Scale and location of haematoma. The mean age was 57.6 years (SD 12.9). Males comprised 88.6% percent of the patients while females comprised 11.3%. One patient in the dexamethasone arm died during the study. At the end of 6 weeks, there was a statistically significant difference in satisfactory radiological resolution between patients in the dexamethasone arm (89.3%) compared to the placebo arm (56%) (p=0.0034). Participants in the dexamethasone arm were 65.3% times more likely to have resolution of the haematoma (Relative Risk 1.6593 (95% CI 1.15 to 2.38); Fishers Exact p value = 0.0034. The Number needed to treat was 2.7. There was no significant difference between neurological outcomes in both groups (p= 0.611). There was poor correlation between neurological and radiological resolution with 77% of participants having unsatisfactory radiological resolution, having good neurological scores. A total of 7 out of 52 (13.2%) participants experienced complications, 6 (21.4%) of these were in the dexamethasone arm and 1 (4%) in the placebo arm. 6 of these participants had high blood glucose, while 1 had urosepsis requiring hospitalization. All 4 participants who required a second operation were in the placebo arm. Conclusion: The present data provides Level 2 evidence that use of dexamethasone as an adjunct to surgery in the management of CSDH improves radiological outcomes. There is a significant benefit indicated by a number needed to treat of only 2.7. While there are more complications in participants taking dexamethasone, these complications are minor and reversible once treatment is stopped