Corticosteroids for non-operative treatment of symptomatic Markwalder grades 1 and 2 chronic subdural hematomas: A retrospective study of 35 cases

Objectives: Standard treatment for chronic subdural hematoma (cSDH) consists of burr hole drainage. Corticosteroids reduce cSDH growth by inhibiting inflammation, reducing vascular permeability, and preventing the abnormal accumulation of fluid in the subdural space. Two recent randomized trials concluded that dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo. However, one recent meta-analysis showed that adjuvant corticosteroids reduce recurrence rates. We aim to provide our experience in managing cSDH with corticosteroids as a primary non-operative modality and describe a novel radiological parameter, the thickness/midline (T/M) shift ratio, to predict successful treatment and resolution. Materials and Methods: This is a single-center, retrospective study. Markwalder grading scale (MGS) was used for inclusion. Significant midline shift (MLS) (>1 cm), basal cisternal effacement, and higher MGS scores (3 and 4) (stuporous, comatose, significant neurological deficits) were operated. Only borderline cases (symptomatic, conscious, no/mild focal deficits [roughly corresponding to MGS scores 1 and 2], <1 cm MLS), were prescribed steroids. Outcome measures were symptomatic relief, residual, and recurrence rates. Results: 35 patients were analyzed. Headache was the most common symptom. All had an MGS score of 1 or 2. The mean duration of steroid treatment was 14 days. The mean thickness was 1.4 cm and the mean MLS was 6.1 mm. The mean T/M ratio was 2.2 (0.6–4.1). On follow-up (FU), all had symptomatic improvement and the mean time to improvement was 4 days. Hematomas resolved in >80% of cases on FU scans. Cases with a lesser T/M ratio (T/M ratio <2.2) had significantly better resolution rates. We observed only one recurrence and none showed clinical deterioration. Except for one case of urinary tract infection, there were no other adverse effects attributable to steroids. Conclusion: In our study, steroids were of significant benefit in improving the symptoms. Symptomatic cases with MGS scores of 1 or 2 and a lesser T/M shift ratio may improve with steroids and seem to be a reasonable alternative to surgery or middle meningeal artery embolization. Steroids should not be tried for MGS scores >2. Well-designed prospective trials including both clinical and radiological parameters need to be performed to further clarify our findings.