Steroids Should Not Be Used in Traumatic Brain Contusion
Corticosteroids are not recommended for traumatic brain contusion and should be avoided, as they increase mortality without improving neurological outcomes or reducing intracranial pressure. 1, 2
Evidence Against Steroid Use
The prohibition against steroids in traumatic brain injury is based on high-quality evidence from the landmark CRASH trial, which enrolled over 10,000 patients and demonstrated a significant increase in mortality with high-dose glucocorticoids compared to placebo (relative risk of death 1.18,95% CI: 1.09-1.27). 1, 2, 3 This finding led to a fundamental practice change in TBI management worldwide.
Multiple international guidelines explicitly recommend against corticosteroid use:
- The Brain Trauma Foundation states that corticosteroids should not be used to improve outcomes or reduce intracranial pressure in severe TBI patients (Level III recommendation). 1
- European guidelines for severe TBI management recommend against high-dose glucocorticoids after severe TBI (Grade 1- recommendation with strong agreement). 1
- The Cochrane systematic review concluded that steroids should no longer be routinely used in people with traumatic head injury based on the increased mortality risk. 3
Why Steroids Are Harmful in TBI
The mechanism of harm differs from the theoretical benefits seen in other conditions. While steroids reduce vasogenic edema in brain tumors where the blood-brain barrier is disrupted, traumatic brain contusions involve both cytotoxic and vasogenic edema with variable blood-brain barrier integrity. 1 Administering hypertonic solutions or steroids when the blood-brain barrier is disrupted may paradoxically increase contusion size rather than reduce it. 1
Important Clinical Caveats
Do not confuse TBI protocols with spinal cord injury management. The American Association of Neurological Surgeons explicitly warns against extrapolating methylprednisolone protocols from spinal cord injury (such as NASCIS protocols) to TBI management, as these are entirely different pathophysiological entities. 2, 4
Three specific exceptions where steroids may still be indicated:
- Patients requiring chronic steroid replacement therapy 1
- Those with adrenal suppression 1
- Injury to the hypothalamic-pituitary-adrenal axis 1
These exceptions represent endocrine replacement rather than therapeutic intervention for the brain injury itself.
What to Do Instead
Focus management on proven interventions for elevated intracranial pressure:
- Adequate sedation and analgesia 1
- Osmotic therapy with hypertonic saline or mannitol (as bolus therapy, not continuous hypernatremia) 1
- External ventricular drainage for CSF diversion 1
- Decompressive craniectomy for refractory intracranial hypertension in carefully selected cases 1
- Maintenance of adequate cerebral perfusion pressure 1
Addressing Conflicting Evidence
One small retrospective study suggested potential benefit of dexamethasone for delayed cerebral edema (>7 days post-injury) in mild-to-moderate TBI with contusions. 5 However, this involved only 9 patients without controls and directly contradicts the high-quality evidence from the CRASH trial involving over 10,000 patients. 1, 3 The overwhelming weight of evidence from multiple international guidelines and the largest randomized trial mandates avoiding steroids in all phases of TBI management. 1, 2