Presenting symptoms and functional outcome of chronic subdural hematoma patients

Background Patients with chronic subdural hematoma (CSDH) can present with a variety of signs and symptoms. The relationship of these signs and symptoms with functional outcome is unknown. Knowledge of these associations might aid clinicians in the choice to initiate treatment and may allow them to better inform patients on expected outcomes. Objective To investigate if presenting signs and symptoms influence functional outcome in patients with CSDH. Methods We conducted a retrospective analysis of consecutive CSDH patients in three hospitals. Glasgow Outcome Scale Extended (GOS-E) scores were obtained from the first follow-up visit after treatment. An ordinal multivariable regression analysis was performed, to assess the relationship between the different signs and symptoms on the one hand and functional outcome on the other adjusted for potential confounders. Results We included 1,307 patients, of whom 958 (73%) were male and mean age was 74 (SD +/- 11) years. Cognitive complaints were associated with lower GOS-E scores at follow-up (aOR 0.7, 95% CI: 0.5 - 0.8) Headache and higher Glasgow Coma Scale (GCS) scores were associated with higher GOS-E scores. (aOR 1.9, 95% CI: 1.5-2.3 and aOR 1.3, 95% CI: 1.2-1.4). Conclusion Cognitive complaints are independently associated with worse functional outcome, whereas headache and higher GCS scores are associated with better outcome. The increased probability of unfavorable outcome in patients with CSDH who present with cognitive complaints favors a more prominent place of assessing cognitive status at diagnosis.Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

National survey on the current practice and attitudes toward the management of chronic subdural hematoma

Background Chronic subdural hematoma (CSDH) is a frequent pathological entity in daily clinical practice. However, evidence-based CSDH-guidelines are lacking and level I evidence from randomized clinical trials (RCTs) is limited. In order to establish and subsequently implement a guideline, insight into current clinical practice and attitudes toward CSDH-treatment is required. The aim is to explore current practice and attitudes toward CSDH-management in the Netherlands. Methods A national online survey was distributed among Dutch neurologists and neurosurgeons, examining variation in current CSDH-management through questions on treatment options, (peri)operative management, willingness to adopt new treatments and by presenting four CSDH-cases. Results One hundred nineteen full responses were received (8% of neurologists, N = 66 and 35% of neurosurgeons, N = 53). A majority of the respondents had a positive experience with burr-hole craniostomy (93%) and with a conservative policy (56%). Around a third had a positive experience with the use of dexamethasone as primary (30%) and additional (33.6%) treatment. These numbers were also reflected in the treatment preferences in the presented cases. (Peri)operative management corresponded among responding neurosurgeons. Most respondents would be willing to implement dexamethasone (98%) if equally effective as surgery and tranexamic acid (93%) if effective in CSDH-management. Conclusion Variation was found regarding preferential CSDH-treatment. However, this is considered not to be insurmountable when implementing evidence-based treatments. This baseline inventory on current clinical practice and current attitudes toward CSDH-treatment is a stepping-stone in the eventual development and implementation of a national guideline.Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

Dexamethasone therapy versus surgery for chronic subdural haematoma (DECSA trial): study protocol for a randomised controlled trial

Paroxysmal Cerebral Disorder

Dexamethasone therapy versus surgery for chronic subdural haematoma (DECSA trial): study protocol for a randomised controlled trial

BACKGROUND: Chronic subdural haematoma (CSDH) is a common neurological disease with a rapidly rising incidence due to increasing age and widespread use of anticoagulants. Surgical intervention by burr-hole craniotomy (BHC) is the current standard practice for symptomatic patients, but associated with complications, a recurrence rate of up to 30% and increased mortality. Dexamethasone (DXM) therapy is, therefore, used as a non-surgical alternative but considered to achieve a lower success rate. Furthermore, the benefit of DXM therapy appears much more deliberate than the immediate relief from BHC. Lack of evidence and clinical equipoise among caregivers prompts the need for a head-to-head randomised controlled trial. The objective of this study is to compare the effect of primary DXM therapy versus primary BHC on functional outcome and cost-effectiveness in symptomatic patients with CSDH.METHODS/DESIGN: This study is a prospective, multicentre, randomised controlled trial (RCT). Consecutive patients with a CSDH with a Markwalder Grading Scale (MGS) grade 1 to 3 will be randomised to treatment with DXM or BHC. The DXM treatment scheme will be 16 mg DXM per day (8 mg twice daily, days 1 to 4) which is then halved every 3 days until a dosage of 0.5 mg a day on day 19 and stopped on day 20. If the treatment response is insufficient (i.e. persistent or progressive symptomatology due to insufficient haematoma resolution), additional surgery can be performed. The primary outcomes are the functional outcome by means of the modified Rankin Scale (mRS) score at 3 months and cost-effectiveness at 12 months. Secondary outcomes are quality of life at 3 and 12 months using the Short Form Health Survey (SF-36) and Quality of Life after Brain Injury Overall Scale (QOLIBRI), haematoma thickness after 2 weeks on follow-up computed tomography (CT), haematoma recurrence during the first 12 months, complications and drug-related adverse events, failure of therapy within 12 months after randomisation and requiring intervention, mortality during the first 3 and 12 months, duration of hospital stay and overall healthcare and productivity costs. To test non-inferiority of DXM therapy compared to BHC, 210 patients in each treatment arm are required (assumed adjusted common odds ratio DXM compared to BHC 1.15, limit for inferiority < 0.9). The aim is to include a total of 420 patients in 3 years with an enrolment rate of 60%.DISCUSSION: The present study should demonstrate whether treatment with DXM is as effective as BHC on functional outcome, at lower costs.TRIAL REGISTRATION: EUCTR 2015-001563-39 . Date of registration: 29 March 2015

A retrospective controlled study into memory complaints reported by depressed patients after treatment with electroconvulsive therapy and pharmacotherapy or pharmacotherapy only

Few studies have been conducted comparing complaints of memory problems using objective and subjective memory scales in depressed patients who received electroconvulsive therapy (ECT) + pharmacotherapy or treatment with pharmacotherapy only. Patients who suffer from depression according to the Diagnostic and Statistical Manual of Mental Disorder (Fourth Edition) criteria and who were admitted within the past 5 years before this study in a general psychiatric hospital were screened for inclusion. Objective retrograde amnesia was assessed using the Autobiographical Memory Interview and the Amsterdam Media Questionnaire (AMQ). Subjective retrograde amnesia was assessed using the Squire Subjective Memory Questionnaire and the ECT Retrograde Amnesia and Perception Scale (ERAPS), a newly developed scale. Twenty of the 84 patients who received ECT + pharmacotherapy and 30 of the 196 patients who received pharmacotherapy only participated in the study. Patients' ERAPS memory scores were compared with proxies' ERAPS memory scores of the patients to assess the reliability of memory complaints. The ECT + pharmacotherapy group was found to suffer more from memory problems using the AMQ 1990 test. There was also a difference for the proxy's ERAPS memory score, reflecting the conviction of proxies from the ECT + pharmacotherapy patients that these patients suffer more memory problems due to the illness, treatment with pharmacotherapy, or ECT. The differences could not be explained by the influence of determinants for retrograde amnesia. ECT + pharmacotherapy patients did not attribute their memory problems mainly to ECT but put equal "blame" on the depressive illness, treatment with pharmacotherapy, and ECT. The analyses suggest that the AMQ 1990s test is (more) sensitive in registering retrograde amnesia than the other scales used in the study

The sex difference of plasma homovanillic acid is unaffected by cross-sex hormone administration in transsexual subjects.

Contains fulltext : 47682.pdf (publisher's version ) (Open Access)There is a close relationship between the brain and the endocrine system. The brain expresses receptors for sex steroids and is capable of metabolizing these hormones. We explored (1) sex differences in homovanillic acid (HVA), a metabolite of the neurotransmitter dopamine, and (2) the effects of cross-sex steroid administration in transsexual subjects. First, we compared plasma HVA levels between 38 male and 34 female healthy volunteers (not using hormone replacement therapy) of a mean age of 72 years (range 65-84 years). Secondly, we measured plasma HVA levels in 15 male-to-female transsexuals treated with 100 microg ethinyl estradiol/day and 100 mg cyproterone acetate/day for 4 months, and in 17 female-to-male transsexuals treated with testosterone esters (250 mg/2 weeks i.m. for 4 months). Plasma HVA levels were lower in elderly men than in elderly postmenopausal women (geometric mean 25.4 nmol/l (percentile (P)10 4.9; P90 69.8) vs 39.0 nmol/l (19.0; 76.1); P=0.027). In transsexuals before cross-sex hormone administration, genetic males also had lower plasma levels of HVA than genetic females (geometric mean 14.8 nmol/l (P10 7.0; P90 35.0) vs 34.3 nmol/l (21.8; 61.4); P0.5). The pretreatment sex difference in plasma HVA was unaffected after 4 months of cross-sex hormone administration (P=0.003). The sex difference in plasma HVA was not reversed by cross-sex hormone administration in transsexuals, and was also preserved in elderly subjects. This indicated that differences in dopamine gene expression were largely unaffected by exposure to sex hormone levels in adulthood, but must rather be explained by a sex difference in genetic factors or by the organizing effects of sex hormones during early development

VARIABILITY IN SURGICAL DECISION MAKING FOR ACUTE SUBDURAL HEMATOMA: RESULTS OF AN ONLINE QUESTIONNAIRE

Neurosurger