Dexamethasone versus Surgery for Chronic Subdural Hematoma

New England Journal of Medicine, vol. 388, pp. 2230–2240

Abstract

BACKGROUND: The role of glucocorticoids without surgical evacuation in the treatment of chronic subdural hematoma is unclear. 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: 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: 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.).

Authors 17

1. Ishita P. Miah Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   Department of Neurology, Amphia Hospital, Breda, Haaglanden Medical Center

   Departments of Neurology, Haaglanden Medical Center

   Leiden University Medical Center, Leiden, the Departments of Neurology, Haaglanden Medical Center

2. Dana C. Holl Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   Departments of Neurosurgery

   Hague, the Stroke Center

   Public Health

3. Jurre Blaauw Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University of Groningen · Leiden University Medical Center · Erasmus MC · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   Erasmus Medical Center, Rotterdam, the Departments of Neurology

   Public Health

4. Hester Floor Lingsma Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   Public Health

5. Heleen M. den Hertog Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University Medical Center Groningen · University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Isala · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   University of Groningen, University Medical Center Groningen, Groningen, the Department of Neurology, Isala, Zwolle

6. Bram Jacobs Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University of Groningen · Leiden University Medical Center · Erasmus MC · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   Erasmus Medical Center, Rotterdam, the Departments of Neurology

7. Nyika D. Kruyt Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   Departments of Neurology, Haaglanden Medical Center

8. Joukje van der Naalt Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University of Groningen · Leiden University Medical Center · Erasmus MC · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   Erasmus Medical Center, Rotterdam, the Departments of Neurology

9. Suzanne Polinder Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

   University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   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

   Public Health

10. Rob J. M. Groen Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

    University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    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

    Neurosurgery, Haaglanden Medical Center

11. Kuan Hua Kho Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

    University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum · University of Twente

    Affiliation as printed

    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

    Clinical Neurophysiology Group, University of Twente, Enschede

12. Fop van Kooten Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

    University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Neurology, Inc · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    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

    Hague, the Stroke Center

    Neurology

13. Clemens M.F. Dirven Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

    University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    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

    Departments of Neurosurgery

    Hague, the Stroke Center

14. Wilco C. Peul Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

    University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Haga Hospital · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    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

    Department of Neurosurgery, Haga Teaching Hospital

15. Korné Jellema Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

    University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    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

    Leiden University Medical Center, Leiden, the Departments of Neurology, Haaglanden Medical Center

16. Rúben Dammers Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

    University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    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

    Departments of Neurosurgery

    Hague, the Stroke Center

17. Niels Anthony Van Der Gaag Aachen Department of Neurology, Amphia Hospital Haaglanden Medical Center Department of Neurosurgery, Haga Teaching Hospital Stroke Center and the Departments of Neurosurgery, Public Health, and Neurology Erasmus Medical Center Department of Neurology, Isala Department of Neurosurgery, Medisch Spectrum Twente, and the Clinical Neurophysiology Group

    University of Groningen · Leiden University Medical Center · Medisch Centrum Haaglanden · Amphia Ziekenhuis · Haga Hospital · Stichting Haaglanden Medisch Centrum

    Affiliation as printed

    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

    Department of Neurosurgery, Haga Teaching Hospital