Dexamethasone versus Surgery for Chronic Subdural Hematoma.

Aged Female Humans Male Dexamethasone / adverse effects Drainage / adverse effects Glasgow Outcome Scale Glucocorticoids / adverse effects Hematoma, Subdural, Chronic / drug therapy Decompressive Craniectomy

Journal

The New England journal of medicine
ISSN: 1533-4406
Titre abrégé: N Engl J Med
Pays: United States
ID NLM: 0255562

Informations de publication

Date de publication:
15 Jun 2023
Historique:
medline: 16 6 2023
pubmed: 14 6 2023
entrez: 14 6 2023
Statut: ppublish

Résumé

The role of glucocorticoids without surgical evacuation in the treatment of chronic subdural hematoma is unclear. In this multicenter, open-label, controlled, noninferiority trial, we randomly assigned symptomatic patients with chronic subdural hematoma in a 1:1 ratio to a 19-day tapering course of dexamethasone or to burr-hole drainage. The primary end point was the functional outcome at 3 months after randomization, as assessed by the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]). Noninferiority was defined by a lower limit of the 95% confidence interval of the odds ratio for a better functional outcome with dexamethasone than with surgery of 0.9 or more. Secondary end points included scores on the Markwalder Grading Scale of symptom severity and on the Extended Glasgow Outcome Scale. From September 2016 through February 2021, we enrolled 252 patients of a planned sample size of 420; 127 were assigned to the dexamethasone group and 125 to the surgery group. The mean age of the patients was 74 years, and 77% were men. The trial was terminated early by the data and safety monitoring board owing to safety and outcome concerns in the dexamethasone group. The adjusted common odds ratio for a lower (better) score on the modified Rankin scale at 3 months with dexamethasone than with surgery was 0.55 (95% confidence interval, 0.34 to 0.90), which failed to show noninferiority of dexamethasone. The scores on the Markwalder Grading Scale and Extended Glasgow Outcome Scale were generally supportive of the results of the primary analysis. Complications occurred in 59% of the patients in the dexamethasone group and 32% of those in the surgery group, and additional surgery was performed in 55% and 6%, respectively. In a trial that involved patients with chronic subdural hematoma and that was stopped early, dexamethasone treatment was not found to be noninferior to burr-hole drainage with respect to functional outcomes and was associated with more complications and a greater likelihood of later surgery. (Funded by the Netherlands Organization for Health Research and Development and others; DECSA EudraCT number, 2015-001563-39.).

Sections du résumé

BACKGROUND BACKGROUND
The role of glucocorticoids without surgical evacuation in the treatment of chronic subdural hematoma is unclear.
METHODS METHODS
In this multicenter, open-label, controlled, noninferiority trial, we randomly assigned symptomatic patients with chronic subdural hematoma in a 1:1 ratio to a 19-day tapering course of dexamethasone or to burr-hole drainage. The primary end point was the functional outcome at 3 months after randomization, as assessed by the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]). Noninferiority was defined by a lower limit of the 95% confidence interval of the odds ratio for a better functional outcome with dexamethasone than with surgery of 0.9 or more. Secondary end points included scores on the Markwalder Grading Scale of symptom severity and on the Extended Glasgow Outcome Scale.
RESULTS RESULTS
From September 2016 through February 2021, we enrolled 252 patients of a planned sample size of 420; 127 were assigned to the dexamethasone group and 125 to the surgery group. The mean age of the patients was 74 years, and 77% were men. The trial was terminated early by the data and safety monitoring board owing to safety and outcome concerns in the dexamethasone group. The adjusted common odds ratio for a lower (better) score on the modified Rankin scale at 3 months with dexamethasone than with surgery was 0.55 (95% confidence interval, 0.34 to 0.90), which failed to show noninferiority of dexamethasone. The scores on the Markwalder Grading Scale and Extended Glasgow Outcome Scale were generally supportive of the results of the primary analysis. Complications occurred in 59% of the patients in the dexamethasone group and 32% of those in the surgery group, and additional surgery was performed in 55% and 6%, respectively.
CONCLUSIONS CONCLUSIONS
In a trial that involved patients with chronic subdural hematoma and that was stopped early, dexamethasone treatment was not found to be noninferior to burr-hole drainage with respect to functional outcomes and was associated with more complications and a greater likelihood of later surgery. (Funded by the Netherlands Organization for Health Research and Development and others; DECSA EudraCT number, 2015-001563-39.).

Identifiants

DOI: 10.1056/NEJMoa2216767 PMID: 37314705
pubmed: 37314705
doi: 10.1056/NEJMoa2216767
doi:

Substances chimiques

Dexamethasone 7S5I7G3JQL
Glucocorticoids 0

Banques de données

EudraCT
['2015-001563-39']

Types de publication

Comparative Study Equivalence Trial Journal Article Multicenter Study Randomized Controlled Trial

Langues

eng

Sous-ensembles de citation

IM

Pagination

2230-2240

Subventions

Organisme : ZonMw
ID : 843002824
Pays : Netherlands

Investigateurs

Nabil Asahaad (N)
Jurre Blaauw (J)
Anastassia Blanter (A)
Christiaan de Brabander (C)
Ruben Dammers (R)
Clemens M F Dirven (CMF)
Lucille Dorrestijn (L)
Mirjam Droger (M)
Marijke Eurlings (M)
Niels A van der Gaag (NA)
Job Gilhuis (J)
Rob J M Groen (RJM)
Heleen M den Hertog (HM)
Dana C Holl (DC)
Bram Jacobs (B)
Korné Jellema (K)
Raoul Kloppenborg (R)
Kuan H Kho (KH)
Radboud W Koot (RW)
Fop van Kooten (F)
Nyika D Kruyt (ND)
Karlijn de Laat (K)
Hester F Lingsma (HF)
Ishita P Miah (IP)
Walid Moudrous (W)
Joukje van der Naalt (J)
Dharmin Nanda (D)
Wilco C Peul (WC)
Gerben J J Plas (GJJ)
Suzanne Polinder (S)
Judith J G Rath (JJG)
Anouk D Rozeman (AD)
Suzanne M Silvis (SM)
Kiril van Veen (KV)
Victor Volovici (V)
Daniël E de Waard (DE)
Sander Wagenmakers (S)
Robert Walchenbach (R)
Agnes A C M Wertenbroek (AACM)

Informations de copyright

Copyright © 2023 Massachusetts Medical Society.

Auteurs

Ishita P Miah (IP)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.
ORCID: 0000-0003-4676-7955

Dana C Holl (DC)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Jurre Blaauw (J)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Hester F Lingsma (HF)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Heleen M den Hertog (HM)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Bram Jacobs (B)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Nyika D Kruyt (ND)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Joukje van der Naalt (J)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Suzanne Polinder (S)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Rob J M Groen (RJM)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Kuan H Kho (KH)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.
ORCID: 0000-0002-1834-0922

Fop van Kooten (F)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Clemens M F Dirven (CMF)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Wilco C Peul (WC)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Korné Jellema (K)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Ruben Dammers (R)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.

Niels A van der Gaag (NA)

From the Department of Neurology, Amphia Hospital, Breda (I.P.M.), the Departments of Neurology (I.P.M., N.D.K.) and Neurosurgery (W.C.P., N.A.G.), Leiden University Medical Center, Leiden, the Departments of Neurology (I.P.M., K.J.) and Neurosurgery (W.C.P., N.A.G.), Haaglanden Medical Center, and the Department of Neurosurgery, Haga Teaching Hospital (W.C.P., N.A.G.), the Hague, the Stroke Center (D.C.H., F.K., C.M.F.D., R.D.) and the Departments of Neurosurgery (D.C.H., C.M.F.D., R.D.), Public Health (D.C.H., J.B., H.F.L., S.P.), and Neurology (F.K.), Erasmus Medical Center, Rotterdam, the Departments of Neurology (J.B., B.J., J.N.) and Neurosurgery (R.J.M.G.), University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle (H.M.H.), and the Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group, University of Twente, Enschede (K.H.K.) - all in the Netherlands.
ORCID: 0000-0001-8086-9870

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Classifications MeSH

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questionsmedicales.fr › Composés polycycliques › Composés à cycles fusionnés › Stéroïdes › Stéroïdes fluorés › Dexaméthasone › Dexamethasone versus Surgery for Chronic...
questionsmedicales.fr › Procédures de chirurgie opératoire › Drainage › Dexamethasone versus Surgery for Chronic...
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