Is steroid use recommended in patients with Diffuse Axonal Injury (DAI)?

Steroid Use in Diffuse Axonal Injury

Steroids are NOT recommended for patients with diffuse axonal injury (DAI), as there is no evidence of neurological benefit and they significantly increase the risk of infectious complications.

Primary Recommendation

While the available guidelines specifically address spinal cord injury rather than DAI, the evidence against steroid use in traumatic CNS injury is directly applicable and compelling. The French guidelines for traumatic spinal cord injury provide a GRADE 1 recommendation with STRONG AGREEMENT against early steroid administration to improve neurological prognosis 1. This represents the highest level of evidence-based recommendation against their use.

Evidence Base Against Steroids

The rationale for avoiding steroids in traumatic brain and spinal cord injury is based on multiple randomized controlled trials:

• The NASCIS trials demonstrated no meaningful neurological improvement with methylprednisolone 1

  • NASCIS II showed only modest motor score improvements at 6 months in a subgroup treated within 8 hours, without standardized long-term assessment 1
  • NASCIS III found no additional benefit from extended 48-hour administration compared to 24 hours 1
  • Neither trial included proper control groups for definitive comparison 1

• Infectious complications were consistently elevated in steroid-treated patients 1

  • 7% infection rate in steroid groups versus 3% in placebo groups 1
  • Increased pulmonary and urinary tract infections documented 1
  • Higher complication rates with prolonged steroid administration 1

• A large Canadian propensity score analysis found no beneficial effect on one-year motor function but confirmed increased infectious complications 1

Management Focus for DAI

Since there is no specific treatment for the primary axonal damage in DAI, management must focus on preventing secondary brain injury 2:

• Maintain adequate cerebral perfusion with systolic blood pressure >110 mmHg 3
• Control ventilation through intubation and mechanical ventilation with end-tidal CO2 monitoring 3
• Prevent hypocapnia which causes cerebral vasoconstriction and increases ischemia risk 3
• Rapidly correct arterial hypotension using vasopressors (phenylephrine, norepinephrine) 3
• Monitor intracranial pressure in severe cases, treating elevations >20 mmHg 3, 4

Rehabilitation Approach

• Early physical therapy and rehabilitation prevent joint contractures and muscle atrophy 3
• Range of motion exercises should begin as soon as the patient is stabilized 3
• Proper positioning and frequent repositioning prevent pressure sores 3
• Splinting may be necessary to maintain joint alignment 3

Common Pitfall

The most critical pitfall is administering steroids based on outdated protocols or anecdotal experience. The evidence clearly demonstrates that any modest theoretical benefit is outweighed by the substantial increase in life-threatening infections 1. In the context of DAI, where patients already face significant morbidity and mortality risk, adding infectious complications through steroid use worsens outcomes rather than improving them.