What is the role of dexamethasone (corticosteroid) in managing brain swelling related to traumatic brain injury (TBI) according to international or European neurosurgical guidelines?

Dexamethasone is Not Recommended for Brain Swelling in Traumatic Brain Injury

Dexamethasone should not be used for the management of brain swelling related to traumatic brain injury according to European and international neurosurgical guidelines. 1

Evidence Against Corticosteroid Use in TBI

• European Stroke Organisation (ESO) guidelines explicitly recommend against the use of dexamethasone in patients with acute intracerebral hemorrhage outside of randomized controlled trials 1
• No evidence indicates that corticosteroids in conventional or large doses improve outcomes in patients with ischemic brain swelling 1
• Current management guidelines for severe traumatic brain injury do not include corticosteroids as a recommended intervention for controlling intracranial pressure 1
• The evidence from randomized controlled trials has failed to demonstrate beneficial effects of dexamethasone on mortality or neurological outcomes in TBI patients 1

Recommended Interventions for Brain Swelling in TBI

First-Line Interventions

• Control ventilation through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring to maintain appropriate PaCO2 levels 1
• Perform external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 1
• Implement standard ICP management practices including:
  • Restriction of free water to avoid hypo-osmolar fluid 1
  • Avoidance of excess glucose administration 1
  • Minimization of hypoxemia and hypercarbia 1
  • Treatment of hyperthermia 1
  • Elevation of the head of the bed at 20° to 30° to assist venous drainage 1

Second-Line Interventions

• Consider decompressive craniectomy to control intracranial pressure in cases of refractory intracranial hypertension, following multidisciplinary discussion 1
• Use osmotic diuretics such as mannitol (0.25 to 0.5 g/kg IV administered over 20 minutes every 6 hours, with usual maximal dose of 2 g/kg) 1
• Consider hypertonic saline in patients with clinical transtentorial herniation, which has been associated with rapid decreases in ICP 1
• For intubated patients, mild hyperventilation targeting PaCO2 of 30-35 mm Hg can temporarily reduce ICP, though the benefit is short-lived 1

Emerging Research on Dexamethasone in Specific TBI Contexts

• Recent research is investigating dexamethasone specifically for TBI patients with brain contusions and pericontusional edema, but results are preliminary and not yet incorporated into guidelines 2, 3
• A retrospective study suggested that low-dose steroids might benefit a subset of patients with delayed pericontusional edema after mild TBI, but more robust clinical trials are needed to confirm these findings 4
• Current research is exploring alternative approaches to managing cerebral edema, such as RAGE inhibitors, which may provide options without the adverse effects associated with dexamethasone 5

Rationale for Avoiding Corticosteroids in TBI

• Meta-analysis of studies reporting one-month case mortality showed no difference in the risk of death between dexamethasone treatment and control groups (RR 1.14,95% CI 0.91-1.42) 1
• In one RCT, 49% of patients who received dexamethasone treatment had died at 21 days compared with 23% of patients treated with placebo (P < 0.05), suggesting potential harm 1
• No beneficial effect of dexamethasone was found on 6-month case fatality (RR 0.60,95% CI 0.19-1.86) or on poor outcome after one month (RR 0.95% CI 0.83-1.09) 1
• The pathophysiology of TBI-related edema differs from that of tumor-associated edema, where dexamethasone has proven beneficial 5

In conclusion, current European and international guidelines do not support the use of dexamethasone for brain swelling related to traumatic brain injury. Instead, they recommend a range of other interventions including proper ventilation management, CSF drainage, osmotic therapy, and in selected cases, decompressive craniectomy.