Traumatic Brain Injury Research Reveals More Don'ts Than Dos

“We know that there is pituitary insufficiency, both in ICU patients in general and in TBI patients specifically. Low-dose replacement therapy with low-dose corticosteroids decreases vasopressor requirements in patients with head injury. Some clinicians use low-dose steroids quite commonly in the ICU environment. However, there are no randomized trials at all addressing this area. There needs to be a real practice reevaluation, after the findings of the CRASH study,” Dr. Cooper said.

Finally, Dr. Cooper discussed the 2007 study by Temkin et al of magnesium sulfate as a neuroprotectant. In this double-blind trial, 499 patients with moderate or severe TBI were randomized to one of two doses of magnesium or to placebo and treated for five days, beginning within eight hours of injury. The primary outcome variable was a composite measure of mortality, seizures, functional measures, and neuropsychological tests at six months after injury.

The investigators found no benefit from the higher dose of magnesium versus the lower dose on the composite primary outcome, significantly worse outcomes in patients treated with the lower dose of magnesium than in those treated with placebo, and higher mortality among patients taking the higher dose of magnesium than among those taking placebo.

“Craniectomy is a promising tactic,” suggested Dr. Cooper. “The procedure may minimize damage to the underlying brain, when conventional measures to control intracranial pressure have started to fail. It must be noted, though, that no studies have definitively shown us that decreasing intracranial pressure increases favorable outcomes.”

“These data have led clinicians, intensivists, and neurosurgeons to a somewhat pessimistic view of how we could possibly make things better in TBI,” commented Dr. Cooper.