Corticosteroids for acute traumatic brain injury

Background Traumatic brain injury is a leading cause of death and disability. Corticosteroids have been widely used in treating people with traumatic brain injury. Objectives To quantify the effectivness and safety of corticosteroids in the treatment of acute traumatic brain injury. Search strategy Electronic sources: MEDLINE, EMBASE, Cochrane Library and specialised databases searches. Additional hand searching and contact with trialists. Date of the most recent search October 2004. Selection criteria All randomised controlled trials of corticosteroid use in acute traumatic brain injury with adequate or unclear allocation concealment. Data collection and analysis Quality of allocation concealment was scored.Data on numbers of participants randomised, numbers lost to follow up, length of follow up, case fatality rates, disablement, infections and gastrointestinal bleeds were extracted independently and checked. Main results We identified 20 trials with 12303 randomised participants. The effect of corticosteroids on the risk of death was reported in 17 included trials. Due to significant heterogeneuty we did not calculate a pooled estimate of risk of death. The largest trial, with about 80% of all randomised participants, found a significant increase in the risk ratio of death with steroids 1.18 (1.09 to 1.27). For the nine trials that reported death or severe disability, the pooled relative risk was 1.01 (0.91 to 1.11), although this does not yet contain data from the largest trial. For infections the pooled risk ratio from five trials was 1.03 (0.99 to 1.07) and for the ten trials reporting gastrointestinal bleeding 1.23 (0.91 to 1.67). Author's conclusions In the absence of a meta-analysis, we feel most weight should be placed on the result of the largest trial. The increase in mortality with steroids in this trial suggest that steroids should no longer be routinely used in people with traumatic head injury.