Effect of dexamethasone (DXM) therapy in patients with a brain bleed: A comparision of a non-operative treatment versus surgery on patient recovery.

A 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. In several hospitals however, dexamethasone (DXM) therapy is used as a non-surgical alternative, because of possible complications, a recurrence rate up to 30% and mortality associated with surgery. Efficacy of DXM treatment however has yet to be proven in high quality comparison studies by means of a randomized-controlled trial. In addition, beneficial effects of DXM treatment are believed to have a slow onset, in contrast to BHC that drains the hematoma and thus causes immediate relief. The objective of this study is to compare the effect of DXM therapy versus primary surgery on functional outcome in symptomatic patients with CSDH.

The study is designed to prove a superior effect of surgery (by BHC) on functional outcome compared to DXM therapy.

Patients will be evaluated (neurological examination, modified Rankin Score, mRS, Markwalder Grading Score, MGS) at:

- Baseline (day of presentation)

- Discharge

- 2 weeks (combined with follow up CT)

- 3 months (at the outpatient clinic)

- 6 months (by phone) by filling in a questionnaire regarding quality of life (short form 36 heath questionnaire) and mRS grading by phone.

Intervention arm: Patients in the intervention (DXM) arm will receive DMX in a daily dosage of 16 mg (8 mg every 12 hours) on day 1 to 4. Thereafter, DXM will be tapered down by halve every 3 days (4 mg every 12 hours on day 5 to 7, 2 mg every 12 hours on day 8 to 10, 1 mg every 12 hours on day 11 to 13, 0.5 mg every 12 hours on day 14 to 16 and 0.5 mg once a day on day 17 to 19). DXM is administered orally in tablets or intravenously when oral administration is not possible due to the clinical condition of the patient. Subjects in the DXM arm will be treated concomitantly with a proton pump inhibitor (Esomeprazole, 40 mg daily) prophylactic, during the DXM treatment regimen.

Control arm: Participants randomized to the control arm will receive operative treatment by burr hole craniostomy (BHC) with insertion of a subdural drain for 48 hours (as this is standard clinical practice). The surgical procedure (BHC) will be performed according to the current in hospital neurosurgical BHC-protocol (which is identical in all 3 participating neurosurgical hospitals). General or local anaesthesia will be applied, depending on the discretion of the treating neurosurgeon which form will be the safest. After evacuation of the hematoma in the surgical theatre, a subdural drain will be inserted for 48 hours.