Effectiveness Comparisons of Drug Therapy on Chronic Subdural Hematoma Recurrence: A Bayesian Network Meta-Analysis and Systematic Review

Abstract

Objectives: We aim to compare the effectiveness of different drug treatments in improving recurrence in patients with chronic subdural hematoma (CSDH). Methods: Eligible randomized controlled trials (RCTs) and prospective trials were searched in PubMed, Cochrane Library, and Embase, from database inception to December 2021. After the available studies following inclusion and exclusion criteria were screened, the main outcome measures were strictly extracted. Taking the random-effects model, dichotomous data were determined and extracted by odds ratio (OR) with 95% credible interval (CrI), and a surface under the cumulative ranking curve (SUCRA) was generated to calculate the ranking probability of comparative effectiveness among each drug intervention. Moreover, we used the node-splitting model to evaluate inconsistency between direct and indirect comparisons of our network meta-analysis (NMA). Funnel plots were used to evaluate publication bias. Results: From the 318 articles found during initial citation screening, 11 RCTs and 3 prospective trials (n = 3,456 participants) were ultimately included in our study. Our NMA results illustrated that atorvastatin + dexamethasone (ATO+DXM) (OR = 0.06, 95% CrI 0.01, 0.89) was the most effective intervention to improve recurrence in patients with CSDH (SUCRA = 89.40%, 95% CrI 0.29, 1.00). Four drug interventions [ATO+DXM (OR = 0.06, 95% CrI 0.01, 0.89), DXM (OR = 0.18, 95% CrI 0.07, 0.41), tranexamic acid (TXA) (OR = 0.26, 95% CrI 0.07, 0.41), and ATO (OR = 0.41, 95% CrI 0.12, 0.90)] achieved statistical significance in improving recurrence in CSDH patients compared with the placebo (PLB) or standard neurosurgical treatment (SNT) group. Conclusion: Our NMA showed that ATO+DXM, DXM, ATO, and TXA had definite efficacy in improving recurrence in CSDH patients. Among them, ATO+DXM is the best intervention for improving recurrence in patients with CSDH in this particular population. Multicenter rigorous designed prospective randomized trials are still needed to evaluate the role of various drug interventions in improving neurological function or outcome. Systematic Review Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299491), identifier (CRD 42022299491).

Keywords: Bayesian network chronic subdural hematoma; Bayesian network meta-analysis; chronic subdural hematoma; drug therapy; effectiveness; recurrence.

FIGURE 1

Screening chart graph. Abbreviations: TXA, tranexamic acid; DXM, dexamethasone; ATO, atorvastatin; GRS, goreisan; CLX, celecoxib; ATO+DXM, atorvastatin plus dexamethasone; ATB, antithrombotic; PLB or SNT, placebo or standard neurosurgical treatment; RCT, randomized controlled study.

FIGURE 2

Risk of bias assessment.

FIGURE 3

Summary of risk of bias assessment. Risk of bias of included randomized controlled trials or prospective trials (review authors’ judgments about each risk of bias item for each included study: +, low risk; −, high risk; ?, unclear risk).

FIGURE 4

Network plot. Abbreviations: TXA, tranexamic acid; DXM, dexamethasone; ATO, atorvastatin; GRS, goreisan; CLX, celecoxib; ATO+DXM, atorvastatin plus dexamethasone; ATB, antithrombotic; PLB or SNT, placebo or standard neurosurgical treatment.

FIGURE 5

Relative effect sizes of efficacy at posttreatment according to network meta-analysis. Abbreviation: SUCRA, the surface under the cumulative ranking curve.

FIGURE 6

SUCRA plot. The surface under the cumulative ranking curve (SUCRA) was generated to display a simple numerical statistical cumulative ranking probability plot of various interventions. SUCRA is 1 if treatment is certainly at the highest level or highly effective, while zero if it undoubtedly means that the treatment has the worst effect. Abbreviations: TXA, tranexamic acid; DXM, dexamethasone; ATO, atorvastatin; GRS, goreisan; CLX, celecoxib; ATO+DXM, atorvastatin plus dexamethasone; ATB, antithrombotic; PLB or SNT, placebo or standard neurosurgical treatment; SUCRA, the surface under the cumulative ranking curve.

FIGURE 7

Funnel plot. Red line suggests the null hypothesis that study-specific effect sizes do not differ from respective comparison-specific pooled effect estimates. Different colors represent different comparisons. Abbreviations: TXA, tranexamic acid; DXM, dexamethasone; ATO, atorvastatin; GRS, goreisan; CLX, celecoxib; ATO+DXM, atorvastatin plus dexamethasone; ATB, antithrombotic; PLB or SNT, placebo or standard neurosurgical treatment.