Steroids Worsen Outcomes After Traumatic Brain Injury
Do not use corticosteroids in traumatic brain injury—they increase mortality and provide no functional benefit. 1, 2
The Evidence Against Steroids in TBI
The landmark CRASH trial, which enrolled over 10,000 TBI patients, definitively demonstrated that high-dose glucocorticoids increase mortality with a relative risk of death of 1.18 (95% CI: 1.09-1.27) compared to placebo. 1, 2, 3 This represents an 18% increased risk of death without any improvement in functional outcomes or reduction in intracranial pressure. 2, 4
Current guideline recommendations are unequivocal:
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). 2, 4
European guidelines for severe TBI management recommend against high-dose glucocorticoids after severe TBI with a Grade 1- recommendation and strong agreement. 1, 4
The FDA drug label for methylprednisolone explicitly warns that high doses of systemic corticosteroids should not be used for the treatment of traumatic brain injury, citing increased early and late mortality. 5
Why Steroids Are Harmful in TBI
The mechanism of harm relates to the disrupted blood-brain barrier in traumatic brain injury. 4 When the blood-brain barrier is compromised, administering corticosteroids may paradoxically increase contusion size rather than reduce cerebral edema. 4 Additionally, steroids increase the risk of:
- Infectious complications (pooled RR 1.04 for high-dose therapy) 6
- Gastrointestinal bleeding (pooled RR 1.26 for high-dose therapy) 6
- Hyperglycemia and metabolic derangements 5, 7
Critical Pitfalls to Avoid
Do not extrapolate from spinal cord injury protocols. 2, 4 The American Association of Neurological Surgeons explicitly warns against applying methylprednisolone protocols (such as NASCIS protocols used in spinal cord injury) to TBI management, as these represent entirely different pathophysiological entities. 2, 4
Avoid "stress-dose" steroids in acute TBI. 2 The use of stress-dose steroids in the acute phase of TBI shows no benefit for death or disability, with a pooled relative risk of 0.95. 2
The Only Exception: Endocrine Replacement
Steroids may still be indicated in patients requiring chronic steroid replacement therapy, those with adrenal suppression, or injury to the hypothalamic-pituitary-adrenal axis. 4 This represents endocrine replacement rather than therapeutic intervention for the brain injury itself. 4
What to Do Instead for Elevated ICP
Focus on proven interventions for managing intracranial pressure:
Osmotic therapy: Use hypertonic saline or mannitol as bolus therapy (not continuous hypernatremia) for elevated intracranial pressure. 4
Adequate sedation and analgesia to control ICP. 4
External ventricular drainage for CSF diversion when appropriate. 4
Decompressive craniectomy for refractory intracranial hypertension in carefully selected cases. 4
Maintain adequate cerebral perfusion pressure as a cornerstone of management. 4
Addressing Recent Contradictory Evidence
One recent 2025 retrospective study suggested potential benefit of low-dose dexamethasone for delayed pericontusional edema in mild TBI. 8 However, this single-center study of only 27 patients cannot override the high-quality evidence from the CRASH trial with over 10,000 patients. 1, 2, 3 The study authors themselves acknowledge the need for more robust clinical trials before changing practice. 8