Dexamethasone led to worse 6-month functional outcomes and more adverse events in a large, randomized, placebo-controlled trial.
The incidence of chronic subdural hematoma has been increasing as the population ages and the use of antithrombotic therapy widens. Surgical evacuation is the mainstay of treatment, but previous studies have suggested that using dexamethasone to target the inflammation associated with blood products in the subdural space might limit hematoma growth and reaccumulation and reduce the need for surgical intervention in some cases. However, these hypotheses and the precise effect of dexamethasone on clinical outcomes have escaped a more rigorous evaluation, until now. In a multicenter trial, 748 patients with symptomatic chronic subdural hematoma (identified radiographically) were randomized to receive either a 2-week dexamethasone taper or placebo. Symptoms included headache, gait disturbance, confusion or cognitive decline, limb weakness, speech disturbance, drowsiness or decreased consciousness, and seizures; asymptomatic patients were not eligible. Surgical evacuations were performed at the discretion of the treating clinicians; nearly all (94%) underwent an initial surgical evacuation.
In the primary analysis of 680 patients, the percentage with a favorable outcome at 6 months (modified Rankin Scale score, 0–3) was lower in the dexamethasone group (84%) than in the placebo group (90%). In secondary analyses, the dexamethasone group had fewer repeat surgical interventions (1.7% vs. 7.1%) but significantly more adverse events such as hyperglycemia, new-onset diabetes, new-onset psychosis, and gastrointestinal bleeding (10.9% vs. 3.2%); more infections (6.4% vs. 1.1%); and more serious adverse events (16.0% vs. 6.4%). An exploratory subgroup analysis of the 38 patients who did not receive surgery also showed worse outcomes with dexamethasone.