Management of Brain Swelling in Traumatic Brain Injury

Evidence Against Corticosteroid Use in TBI

The European Stroke Organisation (ESO) guidelines explicitly recommend against the use of dexamethasone in patients with acute intracerebral hemorrhage outside of randomized controlled trials 1
No evidence indicates that corticosteroids in conventional or large doses improve outcomes in patients with ischemic brain swelling 3
Current management guidelines for severe traumatic brain injury do not include corticosteroids as a recommended intervention for controlling intracranial pressure 2, 4
The evidence from randomized controlled trials has failed to demonstrate beneficial effects of dexamethasone on mortality or neurological outcomes in TBI patients 1, 5

Control ventilation through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring to maintain appropriate PaCO2 levels 4
Perform external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 2
Implement standard ICP management practices including restriction of free water, avoidance of excess glucose administration, minimization of hypoxemia and hypercarbia, treatment of hyperthermia, and elevation of the head of the bed at 20° to 30° to assist venous drainage 3

Consider decompressive craniectomy to control intracranial pressure in cases of refractory intracranial hypertension, following multidisciplinary discussion 2, 4
Use osmotic diuretics such as mannitol (0.25 to 0.5 g/kg IV administered over 20 minutes every 6 hours, with usual maximal dose of 2 g/kg) 3
Consider hypertonic saline in patients with clinical transtentorial herniation, which has been associated with rapid decreases in ICP 3
For intubated patients, mild hyperventilation targeting PaCO2 of 30-35 mm Hg can temporarily reduce ICP, though the benefit is short-lived 3

Meta-analysis of studies reporting one-month case mortality showed no difference in the risk of death between dexamethasone treatment and control groups (RR 1.14, 95% CI 0.91-1.42) 5
In one RCT, 49% of patients who received dexamethasone treatment had died at 21 days compared with 23% of patients treated with placebo (P < 0.05), suggesting potential harm 5
No beneficial effect of dexamethasone was found on 6-month case fatality (RR 0.60, 95% CI 0.19-1.86) or on poor outcome after one month (RR 0.95, 95% CI 0.83-1.09) 5