Dexamethasone Therapy in Symptomatic Chronic Subdural Hematoma (DECSA-R): A Retrospective Evaluation of Initial Corticosteroid Therapy versus Primary Surgery.

Worldwide, different strategies are being applied for symptomatic chronic subdural hematoma (CSDH). The aim of this study was to evaluate the efficacy of two treatment strategies for symptomatic CSDH: initial dexamethasone (DXM) therapy versus primary surgery by burr hole craniostomy (BHC). We retrospectively collected data for 120 symptomatic CSDH patients in two neurotrauma centers between 2014 and 2016, each with their own treatment protocol. Sixty patients received primary BHC (center A), and another 60 initial DXM therapy (center B). Primary outcome was evaluated by dichotomized modified Rankin Scale (mRS) score (0-3 and 4-6) and Markwalder Grading Scale (MGS) score at 3 months. Secondary outcomes were additional interventions, CSDH recurrence, mortality, complications, and duration of hospital stay. Baseline characteristics were similar in both groups. At 3 months, a favorable mRS score (0-3) was observed in 70% and 76% of patients in cohort A and B, respectively (odds ratio [OR] 0.77, 95% CI 0.30-1.98; p = 0.59). A favorable MGS score (0-1) was observed in 96% of patients in both groups (OR 0.98, 95% CI 0.45-2.15; p = 0.95). CSDH recurrence was 12% in cohort A and 22% in cohort B (p = 0.15). Mortality was 10% in both cohorts. In cohort B, additional surgery was performed in 83% at a median of 6 days, and significantly more patients had complications (55% vs. 35%, p = 0.02), a prolonged hospitalization (10 vs. 5 days; p = 0.02), and one or more follow-up cranial CT's (85% vs. 48%; p < 0.001). To achieve a favorable clinical outcome, initial DXM therapy was associated with a high rate of crossover to surgery, significantly longer overall hospital stay, and more complications compared with primary surgery.

Ischaemic stroke as initial presentation of systemic malignancy.

Ischaemic stroke as the initial presentation of systemic malignancy is reported infrequently and is characterised by ischaemic lesions that exceed the vascular territory of a single vessel. There is also a high rate of early stroke recurrence. Several pathophysiological mechanisms are known to cause cerebrovascular complications in malignancies, as a direct effect of the tumour, paraneoplastic or even of the tumour treatment itself. Prognosis is reportedly poor, treatment is symptomatic and at best anecdotal. We present a case report and available literature.