Hemodynamic steroid responsiveness is predictive of neurological outcome after traumatic brain injury.
BACKGROUND
To determine the impact of physiologic doses of hydrocortisone on neurologic outcome after traumatic brain injury (TBI).


METHODS
We conducted a retrospective study in a neurocritical care unit at a university teaching hospital. We included 29 patients with moderate and severe TBI requiring vasoactive drugs to maintain adequate arterial blood pressure who received corticosteroid. Infected patients were excluded. Blood cortisol levels were measured before and 30 and 60 minutes after the administration of a high-dose corticotropin stimulation test (HDST). Patients received hydrocortisone replacement therapy (200-300 mg/day) and vasoactive drugs requirements were noted. Intracranial pressure was managed according to a predefined protocol.


RESULTS
A total of 14 out of 29 (48%) of patients were classified as responders to hydrocortisone (stopping vasoactive drugs within 3 days of starting hydrocortisone). The Glasgow Outcome Score (GOS) was used to assess neurologic outcome at 6 months. A favorable outcome (GOS 4 and 5) was observed in 11 out of 14 (79%) of responders and five out of 15 (33%) of nonresponders (p = 0.03). Of the responders, 12 out of 14 (85%) had a baseline cortisol below 414 nmol/L, and five out of 14 (36%) had primary adrenal insufficiency (AI) (primary AI: low baseline cortisol, and poor response to the HDST). Age, severity of injury, and response to hydrocortisone were predictive of outcome in multiple logistic regression analysis.


CONCLUSIONS
Adrenal insufficiency is frequent after TBI, and hydrocortisone replacement therapy seems to be associated with a favorable neurologic outcome.
Bernard
Francis
F
University Department of Critical Care Medicine and General Internal Medicine, Hôpital du Sacré-Coeur, Montréal, Québec, Canada. bernard.francis@gmail.com
Outtrim
Joanne
J
Lynch
Andrew G
AG
Menon
David K
DK
Matta
Basil F
BF
D000309:Adrenal Insufficiency / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy; D000328:Adult; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage*; D001794:Blood Pressure / Q000187:drug effects*; D001930:Brain Injuries / Q000097:blood / Q000175:diagnosis* / Q000188:drug therapy*; D020208:Brain Injury, Chronic / Q000097:blood / Q000175:diagnosis* / Q000188:drug therapy*; D003366:Cosyntropin; D004305:Dose-Response Relationship, Drug; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage* / Q000097:blood*; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000187:drug effects*; D011379:Prognosis; D012189:Retrospective Studies; D014662:Vasoconstrictor Agents / Q000008:administration & dosage
D000893:Anti-Inflammatory Agents; D014662:Vasoconstrictor Agents; D003366:Cosyntropin; D006854:Hydrocortisone