Miah Ishita P, Blanter Anastassia, Tank Yeliz, Zwet Erik W van, Rosendaal Frits R, Peul Wilco C, Dammers Ruben, Holl Dana C, Lingsma Hester F, den Hertog Heleen M, van der Naalt Joukje, Jellema Korné, der Gaag Niels A Van
Department of Neurology, Amphia Hospital, Breda, the Netherlands.
Department of Neurology and Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands.
J Neurotrauma. 2023 Feb;40(3-4):228-239. doi: 10.1089/neu.2022.0024. Epub 2022 Oct 7.
The main treatment strategy for chronic subdural hematoma is surgical intervention. When a conservative pharmacological approach is considered in symptomatic patients, mainly dexamethasone therapy is applied. Recent trials revealed dexamethasone therapy to be an ineffective treatment in symptomatic patients with chronic subdural hematoma. Whether the efficacy of dexamethasone therapy differs in radiological hematoma subtypes is unknown. The aim of this substudy was to identify which hematoma subtype might be favorable for dexamethasone therapy. As part of a randomized controlled trial, symptomatic chronic subdural hematoma patients received 19-days dexamethasone therapy. The primary outcome measure was the change in hematoma size as measured on follow-up computed tomography (CT) after 2 weeks of dexamethasone in six hematoma (architectural and density) subtypes: homogeneous total, laminar, separated and trabecular architecture types, and hematoma without hyperdense components (homogeneous hypodense, isodense) and with hyperdense components (homogeneous hyperdense, mixed density). We analyzed hematoma thickness, midline shift, and volume using multi-variable linear regression adjusting for age, sex and baseline value of the specific radiological parameter. From September 2016 until February 2021, 85 patients were included with a total of 114 chronic subdural hematoma. The mean age was 76 years and 25% were women. Larger decrease in hematoma thickness and midline shift was revealed in hematoma without hyperdense components compared with hematoma with hyperdense components (adjusted [adj.] -2.2 mm, 95% confidence interval [CI] -4.1 to -0.3 and adj. -1.3 mm, 95% CI -2.7 to 0.0 respectively). Additional surgery was performed in 57% of patients with the highest observed rate (81%) in separated hematoma. Largest hematoma reduction and better clinical improvement was observed in chronic subdural hematoma without hyperdense components after dexamethasone therapy. Evaluation of these parameters can be part of an individualized treatment strategy.
慢性硬膜下血肿的主要治疗策略是手术干预。对于有症状的患者，若考虑采用保守的药物治疗方法，主要应用地塞米松治疗。近期试验表明，地塞米松治疗对有症状的慢性硬膜下血肿患者无效。地塞米松治疗在不同放射学血肿亚型中的疗效是否存在差异尚不清楚。本亚研究的目的是确定哪种血肿亚型可能对地塞米松治疗有利。作为一项随机对照试验的一部分，有症状的慢性硬膜下血肿患者接受了为期19天的地塞米松治疗。主要结局指标是在六种血肿（结构和密度）亚型中，地塞米松治疗2周后，通过随访计算机断层扫描（CT）测量的血肿大小变化：均匀性全血肿、层状血肿、分隔性血肿和小梁状结构血肿，以及无高密度成分的血肿（均匀性低密度、等密度）和有高密度成分的血肿（均匀性高密度、混合密度）。我们使用多变量线性回归分析血肿厚度、中线移位和体积，并对年龄、性别和特定放射学参数的基线值进行了校正。从2016年9月至2021年2月，共纳入85例患者，总计114个慢性硬膜下血肿。平均年龄为76岁，女性占25%。与有高密度成分的血肿相比，无高密度成分的血肿的血肿厚度和中线移位下降幅度更大（校正后分别为-2.2mm，95%置信区间[CI]-4.1至-0.3和校正后-1.3mm，95%CI-2.7至0.0）。57%的患者接受了额外手术，其中分隔性血肿患者的手术率最高（81%）。地塞米松治疗后，无高密度成分的慢性硬膜下血肿的血肿缩小最大，临床改善也更好。对这些参数的评估可作为个体化治疗策略的一部分。
