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The steroid dexamethasone should not be prescribed for people with chronic subdural haematoma (a collection of blood in the space between the skull and the brain). New research found that people who received dexamethasone went on to have more disability and less independence than those who received dummy (placebo) treatment.
Chronic subdural haematoma is usually caused by minor head injury and is common in older people. Symptoms can include an ever-worsening headache, increasing confusion, difficulty walking and arm or leg weakness. It is usually treated with surgery to remove the blood, but it returns in 10-20% people.
If the haematoma is small or the symptoms are mild, some clinicians prescribe dexamethasone. Their aim is to avoid the need for surgery or repeat surgery. However, there is a lack of research to show whether taking dexamethasone has an impact on disability and how well people can manage their everyday activities.
In a new trial, dexamethasone was compared with placebo in people with chronic subdural haematoma. People who received dexamethasone did not have better outcomes (for instance more independence) than those who received placebo, it found.
The drug was linked to more adverse reactions, such as infections or a new diagnosis of diabetes or of psychosis. However, dexamethasone resulted in fewer repeated surgeries.
What’s the issue?
A chronic subdural haematoma is a collection of blood in the space between the skull and the brain. It is particularly common in older people and is usually caused by a minor head injury. It is also common in people taking drugs to prevent blood clots (anticoagulant and antiplatelet medicines). Subdural haematoma is becoming more common as the population ages.
The haematoma causes pressure on the brain. Symptoms can include an ever-worsening headache, increasing confusion, difficulty walking and arm or leg weakness. It is diagnosed using a brain scan.
Most people with a chronic subdural haematoma have surgery to remove it. However, the haematoma returns after surgery in 10 to 20% of people. Dexamethasone is sometimes given to avoid surgery if the haematoma is small and the symptoms mild. Alternatively, it is given alongside surgery to stop the haematoma from returning, and reduce the need for a second procedure.
However, there is little evidence to show that dexamethasone improves outcomes, such as people's independence. This study looked at the difference in patient outcomes between people receiving dexamethasone and others receiving placebo.
The study took part in 23 UK centres. Researchers analysed data on 680 people with an average age of 74 years; all had chronic subdural haematoma. Half the participants received a 2-week course of oral dexamethasone. The dose was reduced slowly over 2 weeks. The other participants received placebo. Most people (94%) in this study had surgery to remove their haematomas.
Participants completed a questionnaire (called the modified Rankin scale) when they entered the study, and then again 6 months later. The scale is commonly used in neurological disorders, including stroke, and it assesses how well people can cope with everyday activities. Scores run from 0 (no disability) through to 6 (death). A 'favourable' score is between 0 – 3 and means people have no more than moderate disability and can walk without help. A 'poor' score is 4+, and people cannot attend to their bodily needs without assistance.
The researchers compared the scores of patients who had been given dexamethasone with those on placebo. They found that, 6 months after treatment:
- fewer people in the dexamethasone group had a favourable score than those receiving placebo (84% compared with 90%)
- twice as many people in the dexamethasone group scored poorly than in the placebo group (17% compared with 8.6%)
- more people in the dexamethasone group reported serious adverse reactions than those taking placebo (16% compared with 6%); these reactions included high blood sugar, new onset diabetes, infections, and gastrointestinal side effects.
One positive effect of dexamethasone was that fewer people taking it needed a repeat operation for haematoma than those on placebo (1.7% compared with 7.1%).
Only 38 people in this study did not have surgery to remove their haematomas. In this small group, people who took dexamethasone were less likely to have a favourable score at 6 months than those on placebo. All 16 people on placebo had a favourable score, compared with 18 out of 22 who received dexamethasone.
Why is this important?
Fewer people treated with dexamethasone in this study had favourable outcomes compared to people receiving dummy treatment. The researchers say that dexamethasone could be doing more harm than good. It was linked with more adverse reactions than dummy treatment. They recommend that clinicians stop prescribing dexamethasone to patients with subdural haematoma.
The numbers in this study were not large enough to say whether dexamethasone prevented the need for surgery. However, fewer people who took dexamethasone had repeat surgery, than those who took placebo.
The Society of British Neurological Surgeons is working with other specialist associations to issue new and updated guidance based on the study findings. The study found a clear signal of harm associated with dexamethasone.
The authors recommend that dexamethasone for chronic subdural haematoma should only be used as part of a research study. Further studies could explore different doses or length of treatment with dexamethasone. It is possible that this could reduce the number of adverse reactions.
The authors say that surgery for chronic subdural haematoma has a good safety profile. Most (90%) patients having surgery had a favourable outcome and almost two-thirds (65%) returned to their usual activities afterwards. They say research should focus on rehabilitation and integrated geriatric care to further improve people’s recovery.
The number of people with this condition is expected to continue rising. Well-designed studies are therefore needed, for example, to explore minimally invasive techniques carried out under local anaesthetic. The researchers say that studies should have outcomes relevant to patients and focus, for example, on their degree of disability.
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This NIHR Alert is based on: Hutchinson P, and others. Trial of dexamethasone for chronic subdural haematoma. The New England Journal of Medicine 2020;383:2616-2627
A review of papers looking at dexamethasone in chronic subdural haematoma and highlighting the need for a well-controlled trial exploring the treatment: Berghauser Pont LME, and others. The role of corticosteroids in the management of chronic subdural hematoma: a systematic review. European Journal of Neurology 2012;19:1397-1403
Funding: This research is supported by the NIHR Health Technology Assessment Programme.
Conflicts of Interest: One of the authors had shares in Marker Diagnostics.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.