A hypothesis accounting for the inconsistent benefit of glucocorticoid therapy in closed head trauma

Because of disagreement between clinical studies, the American College of Neurological Surgeons (ACNS) most recent recommendation (1996) is that glucocorticoids should not be used in the treatment of closed head trauma (CHT). The current paper reviews clinical studies of glucocorticoids and CHT in order to examine what factors might have accounted for the inconsistent results leading to the ACNS's recommendation. A careful analysIs of these studies reveals that, contrary to the ACNS's sweeping conclusion, the available data support the use of glucocorticoids for patients with CHT, but only in specific cases. Glucocorticoids may be beneficial in the treatment of CHT uncomplicated by intracranial hemorrhage; in situations where intracranial hemorrhage accompanies CHT, glucocorticoid treatment appears detrimental. The second part of this paper examines possible mechanisms accounting for the differential effectiveness of glucocorticoids in CHT patients with and without intracranial hemorrhage. These mechanisms include vasospasm, free radical damage, blood-borne factors, and glutamate neurotoxicity.