Failure of high-dose steroid therapy to influence intracranial pressure in patients with severe head injury

Abstract

Corticosteroids in standard neurosurgical dosage do not appear to influence recovery from severe head injury or elevated intracranial pressure (ICP), but a much higher dose may be effective. Apparently an abrupt increase in corticosteroid dosage in patients with severe head injury should cause a detectable reduction in ICP and in cerebral elastance within 48 h. Twenty patients with severe head injury, 12 of whom had had surgical decompression of mass lesions, were studied. All patients were artificially ventilated, and had continuous monitoring of ICP and intermittent testing of elastance by measurement of the volume-pressure response (VPR). For the first 12 h after admission, patients received methylprednisolone, 40 mg every 6 h. The dose was then increased abruptly by giving a single dose of 2 g and 500 mg every 6 h for the next 24 h, then tapering rapidly. No significant change in ICP or VPR could be detected after 24 or 48 h of high-dose steroid therapy. Of the 20 patients, 50% had good recovery or were moderately disabled, 15% were severely disabled or vegetative, and 35% had died. The course of ICP and the outcomes in the patients were not significantly different from those seen in 262 patients previously managed in the same way for the high-dose regimen. There was a high incidence of gastric hemorrhage (50%) and of hyperglycemia with glucosuria (85%) in the 20 patients. The negative results in patients with head injury are contrasted with evidence of the benefit of methylprednisolone in patients with brain tumors.