According to the 2017 guidelines for the management of severe traumatic brain injury (TBI) published by the Brain Trauma Foundation, the general use of corticosteroids is not recommended for improving outcomes in TBI or reducing intracranial pressure (ICP). The recommendation is based on the CRASH trial which found that high-dose methylprednisolone was associated with increased mortality in severe TBI patients, for which it is now considered contraindicated. No dexamethasone-specific recommendation was made. [1], [2]
A 2005 Cochrane meta-analysis investigated the efficacy and safety of corticosteroid use for the treatment of acute TBI. While a total of 20 randomized controlled studies were included, an analysis for risk of death could not be performed due to significant heterogeneity. The largest study (CRASH) reported a significant increase in death with steroid use (risk ratio 1.15; 95% confidence interval [CI] 1.07 to 1.24). An individual analysis on dexamethasone was not performed. Identified studies for dexamethasone were older with the most recent being from 1994. Their meta-analysis table suggested that only one study comparing dexamethasone to placebo was significantly in favor of steroids for outcome of death with a risk ratio of 0.42 (95% CI 0.24 to 0.71). The specific study by Faupel et al. was conducted in 1976 and consisted of adults with severe closed head injury who received dexamethasone at various injected doses versus placebo. Because of the age of the study and lack of formal study design at the time of publication, data is limited. Effect on ICP was not observed in the study nor the Cochrane meta-analysis. [3], [4]
A 2016 review article investigated the evidence for corticosteroid use in TBI. The potential benefits from corticosteroids is believed to be exerted by reduction in vasogenic edema and swelling secondary to cerebral neoplasms. However, when reviewing 5 RCTs with a sample size ≥ 100 patients, there was no evidence of benefit. Two of the 5 RCTs observed use of dexamethasone. The first study dosed dexamethasone at 100 mg bolus on day 1, followed by a taper regimen up to day 10. No significant difference in functional or mortality outcomes were reported at 1 and 6 months. The second study included 300 patients with moderate or severe brain injury treated with 500 mg of dexamethasone within the first 3 hours, followed by 200 mg after 3 hours, and 200 mg every 6 hours for 48 hours. There was no difference versus placebo for improvement in glasgow coma scale scores on day 5 or up to 10 months after brain injury. Rates of death and neurologic recovery were also similar. Because of these findings, the authors do not recommend routine use of corticosteroids in TBI patients and even dissuade further investigations towards their use. [5]
Another 2017 article discussing acute management of TBI does not support the use of corticosteroids based on the CRASH trial. Acute management should be focused on preventing hypotension and hypoxia while maintaining cerebral pressure and blood flow. Elevated ICP should be managed using a multimodal strategy consisting of bedside maneuvers, hyperosmolar therapy, cerebrospinal fluid drainage, pentobarbital coma, and decompressive craniectomy. [6]