Middle meningeal artery embolization for chronic subdural hematoma

Middle meningeal artery embolization for chronic subdural hematoma

middlemeningealartery.jpg

Perioperative prophylactic Middle meningeal artery embolization in the setting of surgical evacuation, via either craniotomy or subdural evacuating port system (SEPS), may help to lower the recurrence rate of cSDH 1).

It can be used safely and effectively as an alternative or adjunctive minimally invasive chronic subdural hematoma treatment in elderly and advanced elderly patients 2).

It has been proposed as a curative treatment for chronic subdural hematoma (cSDH), but evidence for the indication and timing is not definitive.

Given the encouraging results with a 91% long-term success rate in the series of Link et al., a large scale clinical trial is warranted 3).

https://clinicaltrials.gov/ct2/show/NCT03307395

Middle meningeal artery embolization for chronic subdural hematoma systematic reviews.

Middle meningeal artery embolization for chronic subdural hematoma case series

A case of a 74-year-old male on aspirin with a history of recurrent symptomatic chronic right-sided subdural hematoma treated successfully with a SEPS and right middle meningeal artery embolization with poly vinyl alcohol (PVA) microparticles. The patient initially presented to the emergency department with headaches, difficulty walking, and left sided hemiparesis. CT Head showed a large chronic right-sided subdural hematoma measuring 2.7 cm thick with 1 cm of leftward shift. Patient underwent placement of a right-sided SEPS and the subdural hematoma decreased in size to 1.0 cm with 2 mm of leftward shift. The patient had resolution of headaches and neurological symptoms and was discharged home. Three months later, the patient returned to the emergency department with headache and left hand numbness. CT Head showed an acute on chronic right-sided subdural hematoma measuring 1.4 cm with 3 mm of leftward shift. Patient underwent right-sided SEPS placement. Repeat CT Head showed reduction in the subdural hematoma to 1.2 cm. The SEPS was removed and the patient had resolution of neurological symptoms. The patient then had a diagnostic cerebral angiogram with PVA microparticle embolization of the right middle meningeal artery. A SEPS was placed at the time of the angiogram to further reduce the size of the subdural hematoma.

Repeat CT Head after SEPS and middle meningeal artery embolization showed decrease in size of the subdural hematoma. Follow-up CT Head showed stability of the subdural hematoma and patient had no further neurological symptoms. Patient was discharged home.

Middle meningeal artery embolization is a useful endovascular technique for reducing the arterial supply to the membranes in chronic subdural hematomas. Middle meningeal artery embolization can reduce the recurrence rate of subdural hematomas 4).


In 1994 a rare case of chronic subdural hematoma associated with a middle meningeal arteriovenous fistula was treated by a combination of embolization and burr hole drainage. This clinical situation might be missed in this era of computed tomography, when cerebral angiography is seldom indicated for the diagnosis of neuro-traumatic diseases. We should bear in mind the possibility of this clinical situation of a chronic subdural hematoma associated with a linear skull fracture crossing the middle meningeal groove in order to avoid possible hemorrhagic complications during surgery for chronic subdural hematoma 5)


1)

Schwarz J, Carnevale JA, Goldberg JL, Ramos AD, Link TW, Knopman J. Perioperative prophylactic middle meningeal artery embolization for chronic subdural hematoma: a series of 44 cases. J Neurosurg. 2021 May 21:1-9. doi: 10.3171/2020.10.JNS202856. Epub ahead of print. PMID: 34020417.
2)

Joyce E, Bounajem MT, Scoville J, Thomas AJ, Ogilvy CS, Riina HA, Tanweer O, Levy EI, Spiotta AM, Gross BA, Jankowitz BT, Cawley CM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Levitt MR, Binning M, Taussky P, Kan P, Grandhi R. Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases. Neurosurg Focus. 2020 Oct;49(4):E5. doi: 10.3171/2020.7.FOCUS20518. PMID: 33002874.
3)

Link TW, Boddu S, Paine SM, Kamel H, Knopman J. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Series of 60 Cases. Neurosurgery. 2019 Dec 1;85(6):801-807. doi: 10.1093/neuros/nyy521. PMID: 30418606.
5)

Komiyama M, Yasui T, Tamura K, Nagata Y, Fu Y, Yagura H. Chronic subdural hematoma associated with middle meningeal arteriovenous fistula treated by a combination of embolization and burr hole drainage. Surg Neurol. 1994 Oct;42(4):316-9. doi: 10.1016/0090-3019(94)90400-6. PMID: 7974127.

Subdural Evacuating Port System (SEPS)

Subdural Evacuating Port System (SEPS)

http://www.medtronic.com/us-en/healthcare-professionals/products/neurological/critical-care/seps-subdural-evacuation-port-system.html

see Integra™ Subdural Evacuation System.


Twist drill craniostomy (TDC) with closed system drainage and Subdural Evacuating Port System is an effective treatment option for chronic subdural hematoma (CSDH).

In a radiological study, all the branches of the middle meningeal artery ran posterior to the coronal suture and the vascular grooves were also located posterior to the coronal suture at the level of the superior temporal line (STL). The average distance of the vascular grooves was 8.0 +/-5.8 mm. Thirty-five procedures were performed. The coronal suture and the STL could be identified clearly on brain CT scans. The mean thickness of the skull and the CSDH at the proposed point was 8 mm (range 5-13 mm) and 20 mm (range 10-28 mm), respectively. All the TDCs except 1 were congruent with the preoperative brain CT scans. One CSDH recurred 1 month after the first operation and was revised using the same procedure. No other complications occurred.

One centimeter anterior to the coronal suture at the level of the STL is suitable as the normal entry point of the TDC for symptomatic CSDH. The thickness of the CSDH can be measured at this point on a preoperative brain CT scan. Furthermore, the entry point on the scalp can be accurately estimated using surface landmarks 1).


The insertion of a subdural drain was associated with a statistically significant reduction in the risk of symptomatic recurrence and the requirement for further surgical intervention of chronic subdural hematoma after surgical evacuation. Furthermore, it was associated with statistically significant improvements in both short-term and long-term functional outcome 2).

The Subdural Evacuating Port System (SEPS) is a subdural drain that permits the neurosurgeon to drain subacute or chronic subdural hematoma by a method which is minimally invasive, simple and safe to the standard procedure of burr-hole evacuation 3) 4) 5) 6).

The appearance of the winged canula positioned with its tip in the diploic space overlying the subdural space should allow the radiologist to identify it correctly 7).

Because chronic SDH frequently occurs in elderly patients with multiple comorbidities, the bedside approach afforded by the subdural evacuating port system (SEPS) is an attractive alternative method that is performed under local anesthesia and conscious sedation.

A prospectively maintained database of 23 chronic SDHs treated by bur hole or craniotomy and of 23 chronic SDHs treated by SEPS drainage at Tufts Medical Center was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcome was collected. The volume of SDH before and after treatment was semiautomatically measured using imaging software.

There was no significant difference in initial SDH volume (94.5 cm(3) vs 112.6 cm(3), respectively; p = 0.25) or final SDH volume (31.9 cm(3) vs 28.2 cm(3), respectively; p = 0.65) between SEPS drainage and traditional methods. In addition, there was no difference in mortality (4.3% vs 9.1%, respectively; p = 0.61), length of stay (11 days vs 9.1 days, respectively; p = 0.48), or stability of subdural evacuation (94.1% vs 83.3%, respectively; p = 0.60) for the SEPS and traditional groups at an average follow-up of 12 and 15 weeks, respectively. Only 2 of 23 SDHs treated by SEPS required further treatment by bur hole or craniotomy due to inadequate evacuation of subdural blood.

This results means thats a safe and effective alternative to traditional methods of evacuation of chronic SDHs and should be considered in patients presenting with a symptomatic chronic SDH 8).

The SEPS is relatively simple to use and may be especially useful to emergency department staff in outlying areas where there is a shortage of neurosurgical coverage 9).

This technique should be added to the armament of treatment options for a neurosurgeon to treat or temporize a hyperacute SDH with increased intracranial pressure in specific patients 10).

Despite decreasing length of stay LOSs as treatment for cSDH evolved from burr holes BHs to SEPS, the LOS for a cSDH is still longer than that of a patient undergoing craniotomy for brain tumor 11).

The efficacy and safety of SEPS is similar to that of other twist-drill methods reported in the literature. The efficacy of this treatment as measured by radiographic worsening or the need for a subsequent procedure is statistically similar to that of bur hole treatment. There was no difference in mortality or other adverse outcomes associated with SEPS 12).

Specifically, hypodense subdural collections drain more effectively through an SEPS than do mixed density collections. Although significant bleeding after SEPS insertion was uncommon, 1 patient required urgent surgical hematoma evacuation due to iatrogenic injury 13).

The SEPS a first-line treatment for the majority of patients with cSDH, management of cSDH must be tailored to each patient. In mixed density collections with large proportions of acute hemorrhage and in collections with numerous intrahematomal septations, alternative surgical techniques should be considered as first-line therapies 14).

Carpenter et al. evaluated the experience with middle meningeal artery embolization (MMA) combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with chronic subdural hematoma (cSDH). A single-institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization, and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have a shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for chronic subdural hematoma patients with significant comorbidities who are poor surgical candidates 15).


1)

Hwang SC, Im SB, Kim BT, Shin WH. Safe entry point for twist-drill craniostomy of a chronic subdural hematoma. J Neurosurg. 2009 Jun;110(6):1265-70. doi: 10.3171/2008.9.JNS08359. PubMed PMID: 19099378.
2)

Alcalá-Cerra G, Young AM, Moscote-Salazar LR, Paternina-Caicedo A. Efficacy and safety of subdural drains after burr-hole evacuation of chronic subdural hematomas: systematic review and meta-analysis of randomized controlled trials. World Neurosurg. 2014 Dec;82(6):1148-57. doi: 10.1016/j.wneu.2014.08.012. Epub 2014 Aug 10. Review. PubMed PMID: 25118059.
3)

Asfora WT, Schwebach L, Louw D. A modified technique to treat subdural hematomas: the subdural evacuating port system. S D J Med. 2001 Dec;54(12):495-8. PubMed PMID: 11775490.
4)

Asfora WT, Schwebach L. A modified technique to treat chronic and subacute subdural hematoma: technical note. Surg Neurol. 2003 Apr;59(4):329-32; discussion 332. PubMed PMID: 12748020.
5)

Scotton WJ, Kolias AG, Ban VS, Crick SJ, Sinha R, Gardner A, Massey K, Minett T, Santarius T, Hutchinson PJ. Community consultation in emergency neurosurgical research: lessons from a proposed trial for patients with chronic subdural haematomas. Br J Neurosurg. 2013 Oct;27(5):590-4. doi:10.3109/02688697.2013.793291. Epub 2013 Jun 14. PubMed PMID: 23767683.
6)

Singla A, Jacobsen WP, Yusupov IR, Carter DA. Subdural evacuating port system (SEPS)–minimally invasive approach to the management of chronic/subacute subdural hematomas. Clin Neurol Neurosurg. 2013 Apr;115(4):425-31. doi: 10.1016/j.clineuro.2012.06.005. Epub 2012 Jul 3. PubMed PMID: 22763191.
7)

Lollis SS, Wolak ML, Mamourian AC. Imaging characteristics of the subdural evacuating port system, a new bedside therapy for subacute/chronic subdural hematoma. AJNR Am J Neuroradiol. 2006 Jan;27(1):74-5. PubMed PMID: 16418360.
8)

Safain M, Roguski M, Antoniou A, Schirmer CM, Malek AM, Riesenburger R. A single center’s experience with the bedside subdural evacuating port system: a useful alternative to traditional methods for chronic subdural hematoma evacuation. J Neurosurg. 2013 Mar;118(3):694-700. doi: 10.3171/2012.11.JNS12689. Epub 2012 Dec 21. Erratum in: J Neurosurg. 2013 Jul;119(1):256. Schirmer, Clemens S [corrected to Schirmer, Clemens M]. PubMed PMID: 23259822.
9)

Asfora WT, Klapper HB. Case report: treatment of subdural hematoma in the emergency department utilizing the subdural evacuating port system. S D Med. 2013 Aug;66(8):319-21. PubMed PMID: 24175497.
10)

Ivan ME, Nathan JK, Manley GT, Huang MC. Placement of a subdural evacuating port system for management of iatrogenic hyperacute subdural hemorrhage following intracranial monitor placement. J Clin Neurosci. 2013 Dec;20(12):1767-70. doi: 10.1016/j.jocn.2013.03.009. Epub 2013 Oct 3. PubMed PMID: 24090520.
11)

Balser D, Rodgers SD, Johnson B, Shi C, Tabak E, Samadani U. Evolving management of symptomatic chronic subdural hematoma: experience of a single institution and review of the literature. Neurol Res. 2013 Apr;35(3):233-42. doi: 10.1179/1743132813Y.0000000166. Review. PubMed PMID: 23485050.
12)

Rughani AI, Lin C, Dumont TM, Penar PL, Horgan MA, Tranmer BI. A case-comparison study of the subdural evacuating port system in treating chronic subdural hematomas. J Neurosurg. 2010 Sep;113(3):609-14. doi: 10.3171/2009.11.JNS091244. PubMed PMID: 20001585.
13)

Kenning TJ, Dalfino JC, German JW, Drazin D, Adamo MA. Analysis of the subdural evacuating port system for the treatment of subacute and chronic subdural hematomas. J Neurosurg. 2010 Nov;113(5):1004-10. doi: 10.3171/2010.5.JNS1083. Epub 2010 May 28. PubMed PMID: 20509728.
14)

Neal MT, Hsu W, Urban JE, Angelo NM, Sweasey TA, Branch CL Jr. The subdural evacuation port system: outcomes from a single institution experience and predictors of success. Clin Neurol Neurosurg. 2013 Jun;115(6):658-64. doi: 10.1016/j.clineuro.2012.07.017. Epub 2012 Aug 3. PubMed PMID: 22863544.
15)

Carpenter A, Rock M, Dowlati E, Miller C, Mai JC, Liu AH, Armonda RA, Felbaum DR. Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas. Neurosurg Rev. 2021 Apr 24. doi: 10.1007/s10143-021-01553-x. Epub ahead of print. PMID: 33893872.

Steroids for chronic subdural hematoma

Since glucocorticoids have been used for treatment of chronic subdural hematoma in 1962 their role is still discussed controversially in lack of evident data. On the basis of the ascertained inflammation cycle in cSDH dexamethasone will be an ideal substance for a short lasting, concomitant treatment protocol.

Berghauser et al. stated in 2013 that the proportion of patients primarily treated with corticosteroids are increasing year by year 1)

Patients with lower grades of CSDH can be treated successfully with steroids. Female patients seem to do better with steroids 2).


In 2020 in the The New England Journal of Medicine among adults with symptomatic chronic subdural hematoma, most of whom had undergone surgery to remove their hematomas during the index admission, treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Dex-CSDH ISRCTN number, ISRCTN80782810.) 3).

Surveys

Forty-two percent of surgeons never prescribe steroids and 55% prescribe them to those managed conservatively 4).

In another Canadian survey regarding neurosurgical practice of treatment of CSDH, <15% of neurosurgeons prefer using high-dose corticosteroid 5)

Current evidence implicates a potentially beneficial role of dexamethasone in the management of CSDH. However, it remains unclear whether the rate of crossover to surgery is reduced in patients treated with corticosteroids compared with those managed conservatively. A longer duration of study with detailed analysis of individual cases and appropriately randomized cohorts are necessary to draw more reliable conclusions 6)

Scerrati et al. performed a systematic review according to PRISMA criteria of the studies analyzing the nonsurgical strategies for CSDHs. They collected all papers in the English language published between 1990 and 2019 by searching different medical databases. The chosen keywords were “chronic subdural hematoma,” “conservative treatment/management,” “pharmacological treatment,” “non-surgical,” “tranexamic acid,” “dexamethasone,” “corticosteroid,” “glucocorticoid,” “middle meningeal artery,” “endovascular treatment,” and “embolization.”

The authors ultimately collected 15 articles regarding the pharmacological management of CSDHs matching the criteria, and 14 papers included the endovascular treatment.

The results showed that surgery still represents the mainstay in cases of symptomatic patients with large CSDHs; however, adjuvant and alternative therapies can be effective and safe in a carefully selected population. Their inclusion in new guidelines is advisable 7).


A meta-analysis of Holl et al. from 29019 suggested that the addition of corticosteroids to surgery might be effective in the treatment of CSDH. However, the results must be interpreted with caution in light of the serious risk of bias of the included studies. This study stresses the need for large randomized trials to investigate the use of corticosteroids in the management of CSDH 8)


In 2017 a study of Yao et al. had no enough evidence to support DX use as an effective alternation to surgical therapy. But adjuvant DX use may facilitate the surgical therapy by reducing chronic subdural hematoma recurrence. Further study focusing on adjuvant DX was required 9)

Among adults with symptomatic chronic subdural hematoma, most of whom had undergone surgery to remove their hematomas during the index admission, treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Dex-CSDH ISRCTN number, ISRCTN80782810.) 10).

see DECSA trial.

see SUCRE trial.

A study is designed as a double-blind randomized placebo-controlled trial 820 patients who are operated for cSDH and from the age of 25 years are included after obtaining informed consent. They are randomized for administration of dexamethasone (16-16-12-12-8-4 mg/d) or placebo (maltodextrin) during the first 48 hours after surgery. The type I error is 5% and the type II error is 20%. The primary endpoint is the reoperation within 12 weeks postoperative.

This study tests whether dexamethasone administered over 6 days is a safe and potent agent in relapse prevention for evacuated cSDH 11).

Mebberson et al. presented an interim analysis of the first registered prospective randomised placebo-controlled trial (PRPCT) of adjuvant DX on RR and outcome after CSDH surgery with post-operative drainage. Participants were randomised to either placebo or a reducing DX regime over 2 weeks, with CSDH evacuation and post-operative drainage. Post-operative mortality (POMT) and RR were determined at 30 days and 6 months; modified Rankin Score (mRS) at discharge and 6 months. Post-operative morbidity (POMB) and adverse events (AEs) were determined at 30 days. Interim analysis at approximately 50% estimated sample size was performed (n = 47). Recurrences were not observed with DX: only with placebo (0/23 [0%] v 5/24 [20.83%], P = 0.049). There was no significant between-group differences in POMT, POMB, LOS, mRS or AEs. CONCLUSIONS: In this first registered PRPCT, interim analysis suggested that adjuvant DX with post-operative drainage is both safe and may significantly decrease recurrences. A 12.5% point between-groups difference may be reasonable to power a final sample size of approximately n = 89. Future studies could consider adjuvant DX for longer than the arbitrarily-chosen 2 weeks 12).


Twenty patients with imaging-confirmed CSDH were recruited from a single center and randomized to receive dexamethasone (12 mg/day for 3 weeks followed by tapering) or placebo as a conservative treatment. Patients were followed for 6 months and the rate of success of conservative treatment with dexamethasone versus placebo was measured. Parameters such as hematoma thickness and clinical changes were also compared before and after treatment with chi-square tests. Adverse events and complications were documented.

Results: During the 6-month follow-up, one of ten patients treated with corticosteroids had to undergo surgical drainage and three of ten patients were treated surgically after placebo treatment. At the end of the study, all remaining patients had complete radiological resolution. No significant differences were observed in terms of hematoma thickness profile and impression of change; however, patients experienced more severe side effects when treated with steroids as compared with placebo. Dexamethasone contributed to many serious adverse events.

Given the small sample size, these preliminary results have not shown a clear beneficial effect of dexamethasone against placebo in our patients. However, the number of secondary effects reported was much greater for corticosteroids, and dexamethasone treatment was responsible for significant complications 13).

Sunet al. prospectively studied a group of 30 patients, who were managed non-operatively: 26 patients were treated with dexamethasone (Group 1) and four patients expectantly (Group 4). Nineteen patients (73%) from Group 1 were confused or had focal neurological deficits on admission. The mean maximum thickness of the CSDH was 12 mm. Only one of these cases (4%) required surgical drainage 6 weeks after steroid therapy. One patient died of an unrelated stroke (mortality = 4%). Two patients (8%) were left severely disabled. No significant complication from steroid therapy was documented. Out of the 85 surgically treated patients, 69 patients underwent surgical drainage in addition to steroid therapy (Group 2). Thirteen patients were treated with burr-hole drainage only (Group 3). The mean maximum thickness of the CSDH for these two groups were both 16 mm. Comparing with group 1, the redrainage rate of Group 2 [4% (3/69, p = 1)] and that of Group 3 [15% (2/13, p = 0.253)] were not significantly different. 50% of patients in Group 4 (2/4, p = 0.039) required delayed surgical drainage. The mortality rates of Groups 2, 3 and 4 were 3% (2/69, p = 1), 15% (2/13, p = 0.253) and 50% (2/4, p = 0.039), respectively. Our results suggest that steroid treatment in a selected group of patients is a good option, particularly in patients with co-morbidity 14).


1)

Berghauser Pont LM, Dippel DW, Verweij BH, Dirven CM, Dammers R. Ambivalence among neurologists and neurosurgeons on the treatment of chronic subdural hematoma: a national survey. Acta Neurol Belg. 2013 Mar;113(1):55-9. doi: 10.1007/s13760-012-0130-1. Epub 2012 Sep 14. PMID: 22975837.
2)

Thotakura AK, Marabathina NR. Nonsurgical Treatment of Chronic Subdural Hematoma with Steroids. World Neurosurg. 2015 Dec;84(6):1968-72. doi: 10.1016/j.wneu.2015.08.044. Epub 2015 Sep 2. PMID: 26342776.
3) , 10)

Hutchinson PJ, Edlmann E, Bulters D, Zolnourian A, Holton P, Suttner N, Agyemang K, Thomson S, Anderson IA, Al-Tamimi YZ, Henderson D, Whitfield PC, Gherle M, Brennan PM, Allison A, Thelin EP, Tarantino S, Pantaleo B, Caldwell K, Davis-Wilkie C, Mee H, Warburton EA, Barton G, Chari A, Marcus HJ, King AT, Belli A, Myint PK, Wilkinson I, Santarius T, Turner C, Bond S, Kolias AG; British Neurosurgical Trainee Research Collaborative; Dex-CSDH Trial Collaborators. Trial of Dexamethasone for Chronic Subdural Hematoma. N Engl J Med. 2020 Dec 31;383(27):2616-2627. doi: 10.1056/NEJMoa2020473. Epub 2020 Dec 16. PMID: 33326713.
4)

Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg. 2008 Aug;22(4):529-34. doi: 10.1080/02688690802195381. PMID: 18686063.
5)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. doi: 10.1017/s0317167100004510. PMID: 16408582.
6)

Petralia CCT, Manivannan S, Shastin D, Sharouf F, Elalfy O, Zaben M. Effect of Steroid Therapy on Risk of Subsequent Surgery for Neurologically Stable Chronic Subdural Hemorrhage-Retrospective Cohort Study and Literature Review. World Neurosurg. 2020 Jun;138:e35-e41. doi: 10.1016/j.wneu.2020.01.160. Epub 2020 Feb 27. PMID: 32113994.
7)

Scerrati A, Visani J, Ricciardi L, Dones F, Rustemi O, Cavallo MA, De Bonis P. To drill or not to drill, that is the question: nonsurgical treatment of chronic subdural hematoma in the elderly. A systematic review. Neurosurg Focus. 2020 Oct;49(4):E7. doi: 10.3171/2020.7.FOCUS20237. PMID: 33002869.
8)

Holl DC, Volovici V, Dirven CMF, van Kooten F, Miah IP, Jellema K, Peul WC, van der Gaag NA, Kho KH, den Hertog HM, Dammers R, Lingsma HF. Corticosteroid treatment compared with surgery in chronic subdural hematoma: a systematic review and meta-analysis. Acta Neurochir (Wien). 2019 Jun;161(6):1231-1242. doi: 10.1007/s00701-019-03881-w. Epub 2019 Apr 10. PMID: 30972566.
9)

Yao Z, Hu X, Ma L, You C. Dexamethasone for chronic subdural haematoma: a systematic review and meta-analysis. Acta Neurochir (Wien). 2017 Nov;159(11):2037-2044. doi: 10.1007/s00701-017-3309-7. Epub 2017 Sep 1. PMID: 28865006.
11)

Emich S, Richling B, McCoy MR, Al-Schameri RA, Ling F, Sun L, Wang Y, Hitzl W. The efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematoma – the DRESH study: straightforward study protocol for a randomized controlled trial. Trials. 2014 Jan 6;15(1):6. doi: 10.1186/1745-6215-15-6. PubMed PMID: 24393328; PubMed Central PMCID: PMC3891985.
12)

Mebberson K, Colditz M, Marshman LAG, Thomas PAW, Mitchell PS, Robertson K. Prospective randomized placebo-controlled double-blind clinical study of adjuvant dexamethasone with surgery for chronic subdural haematoma with post-operative subdural drainage: Interim analysis. J Clin Neurosci. 2020 Jan;71:153-157. doi: 10.1016/j.jocn.2019.08.095. Epub 2019 Sep 3. PMID: 31492485.
13)

Prud’homme M, Mathieu F, Marcotte N, Cottin S. A Pilot Placebo Controlled Randomized Trial of Dexamethasone for Chronic Subdural Hematoma. Can J Neurol Sci. 2016 Mar;43(2):284-90. doi: 10.1017/cjn.2015.393. Epub 2016 Feb 8. PMID: 26853325.
14)

Sun TF, Boet R, Poon WS. Non-surgical primary treatment of chronic subdural haematoma: Preliminary results of using dexamethasone. Br J Neurosurg. 2005 Aug;19(4):327-33. doi: 10.1080/02688690500305332. PMID: 16455539.
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