Dexamethasone and severe head injury. A prospective double-blind study

Effects of dexamethasone in primary supratentorial intracerebral hemorrhage

To evaluate the efficacy of dexamethasone for treatment of primary supratentorial intracerebral hemorrhage, we studied 93 patients 40 to 80 years old, using a double-blind randomized block design. After the subjects were stratified according to their level of consciousness (Glasgow Coma Scale), those with objectively documented primary supratentorial intracerebral hemorrhage were randomly assigned to either dexamethasone or placebo. For ethical reasons, three interim analyses were planned, to permit early termination of the trial if one study group did better than the other. During the third interim analysis, the death rate at the 21st day was identical in the two groups (dexamethasone vs. placebo, 21 of 46 vs. 21 of 47; chi-square = 0.01, P = 0.93). In contrast, the rate of complications (mostly infections and complications of diabetes) was much higher in the dexamethasone group (chi-square = 10.89, P less than 0.001), leading to early termination of the study. In the light of the absence of a demonstrable beneficial effect and the presence of a significant harmful effect, current practices of using dexamethasone for treatment of primary supratentorial hemorrhage should be reconsidered.

Physiological and metabolic response to isolated closed-head injury. Part 2: Effects of steroids on metabolism. Potentiation of protein wasting and abnormalities of substrate utilization

In order to determine the effects of steroid administration on the metabolic response to isolated closed-head injury, a longitudinal study was performed. Metabolic indices were prospectively evaluated for the first 5 days postinjury in six patients who received steroids and 10 patients who did not. Patients were carefully screened to eliminate those with associated injuries as well as those with abnormalities due to sepsis. Other than steroid administration, a uniform treatment regimen was used in both groups. Metabolic indices measured on postinjury Days 1, 3, and 5 were analyzed. In addition, data were compared to results in large data banks obtained both from overnight-fasted patients (fasted controls) and from polytrauma victims (stressed controls). Both treatment groups were comparable with respect to age, mean Glasgow Coma Scale scores on admission and on Day 5, and initial intracranial pressure. Metabolic data indicated significantly higher levels of nitrogen excretion and somatic protein mobilization in steroid-treated patients than in patients not receiving steroids. In both groups, glucose levels, the lactate/pyruvate ratio, and branched-chain amino acid levels (all metabolic indices that correlate well with level of stress) initially corresponded to values for stressed controls. By Day 5, values for these variables were similar to fasted controls for the group not receiving steroids. In patients receiving steroids, however, the data remained similar to those for stressed controls. It is concluded that steroids prolong the metabolic abnormalities associated with the initial phase of head injury. In view of inconclusive data regarding benefit from steroid administration, serious questions must be raised regarding the use of these catabolic agents in this setting.

Dexamethasone therapy and cortisol excretion in severe pediatric head injury

Glucocorticoids are used in an attempt to reduce brain edema secondary to head injury. Nevertheless, their usefulness remains uncertain and contradictory. In a randomized study of 24 children with severe head injury, urinary free cortisol was measured by radioimmunoassay. Twelve patients (group 1) received dexamethasone and 12 (group 2) did not. All patients were treated with a standardized regimen. In group 1 there was complete suppression of endogenous cortisol production. In group 2 free cortisol was up to 20-fold higher than under basal conditions and reached maximum values on days 1-3. Since the excretion of cortisol in urine reflects the production rate closely and is not influenced by liver function and barbiturates, the results in group 2 show that the endogenous production of steroids is an adequate reaction to severe head injury. Exogenous glucocorticoids are thus unlikely to have any more beneficial effects than endogenous cortisol.

Effect of dexamethasone on blood-brain barrier in the normal mouse

Dexamethasone ameliorates cerebral edema, but its effect on normal blood-brain barrier is unknown, as is the site of action. Sixteen normal mice were given dexamethasone, 3 mg/kg intramuscularly or 2 mg/kg intravenously. One to two hours later 10 mg of horseradish peroxidase (HRP) in 0.1 ml of saline was administered intravenously and allowed to circulate for 15 minutes. Brain slices were examined by light and electron microscopy. The number of HRP-permeable arteriolar segments per brain was less in dexamethasone-treated than in control mice (p less than 0.001). In addition, the number of small HRP-filled endothelial vesicles of capillaries and of HRP-permeable and -impermeable arterial segments was less in dexamethasone-treated mice than that for similar vessels in control mice (p less than 0.005, p less than 0.05, and p less than 0.01, respectively). The total number of small vesicles and the number of larger HRP-filled vesicles in arterioles was the same in treated and control mice. Dexamethasone therefore decreased the normal permeability of cerebral blood vessels to HRP. This decrease was accompanied by a decrease in the number of HRP-containing small endothelial vesicles. These data suggest that dexamethasone influences cerebral edema by decreasing the permeability of the cerebral vasculature for macromolecules.

Effect of high-dose dexamethasone on outcome from severe head injury

The conflicting evidence concerning the influence of high-dose steroids on intracranial pressure (ICP) and outcome following severe head injury has led to the institution of the prospective double-blind controlled trial reported here. Severely head-injured patients admitted to intensive care during a 3-year period were randomly allocated to a dexamethasone- or placebo-treated group. Adults in the steroid group received dexamethasone, 50 mg intravenously, as a bolus on admission to the neurosurgical unit, then 100 mg on Days 1, 2, and 3, 50 mg on Day 4, and 25 mg on Day 5 on continuous intravenous infusion. Children received proportionate intravenous dosages calculated on a weight basis. Severity of head injury was assessed from admission Glasgow Coma Scale (GCS) scores and the appearance of the admission computerized tomography scan. Intracranial pressure (ICP) was monitored in all patients from the surface subarachnoid space. Outcome at 6 months was assessed using the Glasgow Outcome Scale. Steroid and placebo groups were similar in terms of admission GCS score, intracranial pathology, incidence of associated injuries, and time interval from injury to admission to intensive care. The ICP generally increased during the first 48 hours of intensive therapy; there was no difference in this trend between the steroid and placebo groups. A poorer outcome was observed in patients with elevated ICP who received steroids. No increase in the incidence of pulmonary, gastrointestinal, or other extracranial complications was seen in the steroid group. The 6-month outcome did not differ between the steroid and placebo groups. No advantage of high-dose dexamethasone on ICP trends or clinical outcome in the treatment of severe head injury has emerged from this study.

Modified injury severity scale and concurrent steroid therapy: independent correlates of negative nitrogen balance in pediatric trauma

Twelve well-nourished children with multiple trauma were separately grouped by the presence or absence of a head injury and associated steroid treatment. They were studied to determine the impact of the severity of overall injury (measured by MISS), neurologic injury (measured by GCS), and steroid administration on total urinary nitrogen excretion. All six children with significant head injury received steroids. Nitrogen loss was higher in more severely injured patients. Severity of overall injury was similar in the steroid and nonsteroid treated groups. The nitrogen loss in head-injured patients treated with steroids was significantly greater (P less than 0.001) than in the nonsteroid-treated patients.

Steroid administration and nitrogen excretion in the head-injured patient

The effect of steroid administration on metabolic rate and nitrogen excretion was examined in 20 head-injured patients alternately assigned to receive either methylprednisolone for 14 days or no steroid treatment. Although metabolic rate, caloric intake, and nitrogen intake were not different between the two groups, the patients who received steroids had a 30% higher excretion of nitrogen during the first 6 days after injury than did the patients not receiving steroids. All patients had an increase in nitrogen excretion through the 2nd week, peaking on Day 11. By Day 21 after injury, the patients had an average cumulative nitrogen loss of 162 gm and had lost an average of 5 kg body weight regardless of whether they had received steroids. Serum albumin levels decreased in the steroid-treated patients but returned to nearly normal by Day 21 in the untreated group. Immunosuppression, evidenced by a lower initial total lymphocyte count and a higher incidence of infections, was present in the steroid group; hyperglycemia requiring insulin treatment was more common in those patients.

Septic complications of corticosteroid administration after central nervous system trauma

The records of 197 consecutive multiple trauma patients were reviewed to define the infectious complications of corticosteroids used to treat brain and spinal cord injury. An injury severity score (ISS) and a central nervous system (CNS) injury score were determined for each patient. Patients with an ISS less than 20 did well with or without steroids and were excluded from further study. All deaths that occurred 5 or more days after injury were caused by sepsis, and all occurred in steroid recipients. Twenty-nine of 61 steroid-treated early survivors developed infectious complications, compared to eight of 55 patients who did not receive steroids (47.5% vs. 14.5%, p less than 0.001). There was no correlation between severity of CNS trauma and infectious complication rate. Steroid-treated patients frequently developed multiple pathogen primary infections and multiple, simultaneous septic foci. Patients treated with steroids more often developed infections caused by Staphylococcus aureus, assorted gram negative rods, anerobic bacteria, or fungi. The study strongly suggests a significant increase in both the incidence and severity of infectious complications occurring in patients treated with corticosteroids for CNS trauma.

Current application of "high-dose" steroid therapy for CNS injury. A pharmacological perspective

Although administration of glucocorticoid steroids is one of the most widely used therapeutic modalities for the clinical management of acute trauma of the central nervous system (CNS), controversy continues regarding their effectiveness. In essence, two viewpoints concerning their use exist. Some believe that despite their poor clinical record, the steroids nevertheless have a place in the treatment of human CNS trauma. In general, this group of clinical investigators uses the steroids primarily out of tradition, feeling that steroid therapy may be of some benefit. Unfortunately, confusion remains as to what constitutes an appropriate dose or regimen. In this regard, it has been suggested that the steroid dose be increased and the regimen intensified. Others believe that steroids should not be used. They contend that in view of their poor clinical record, it is unlikely that increasing the steroid dose or changing the dosing regimen will improve clinical efficacy, since steroids have already failed at what may be considered huge doses by glucocorticoid standards. Furthermore, it is contended that the side effects associated with large steroid doses reduce the margin of safety so as to make the steroids unsafe. Complicating these arguments is a body of experimental evidence that by and large strongly supports the utility of steroids for the acute treatment of CNS trauma. The intent of this article is to evaluate the current use of steroid therapy for CNS trauma from a purely pharmacological perspective, and to compare the steroids' experimental use with their clinical application.

Actinomycin D suppresses the protective effect of dexamethasone in rats affected by global cerebral ischemia

Simultaneous occlusion of both common carotid arteries in female Sprague-Dawley CFY rats produced characteristic symptoms of global cerebral ischemia, such as staggering, circling, convulsions, followed by coma and death. A close correlation existed among these symptoms and the elevation of water and Na+ content, appearing at the stage of staggering; Evans blue extravasation and diminution of K+ content, detected at circling; and the increase in Ca2+ content in the total brain tissue, manifesting itself at the phase of convulsions, indicating the development of cerebral edema due to ischemia. Dexamethasone given subcutaneously in a single 2.0 mg kg-1 dose 5 hours prior to the induction of global cerebral ischemia reduced considerably the morbidity and mortality, the alterations in water and electrolyte content, and albumin leakage in the brain tissue. Actinomycin D, in a dose of 0.5 mg kg-1 injected intravenously 1 hour before steroid treatment, abolished the beneficial effect. This finding suggests that de novo protein synthesis is involved in the cerebroprotective effect of dexamethasone.

Outcome from severe head injury in children and adolescents

A consecutive series of 37 children (17 years old and under) with severe head injury is presented. The data confirm that morbidity and mortality are lower in children than in adults: 51% of these young patients had a good recovery or moderate disability at 6 months. The mortality rate in this series (33%) is higher than in some reports, but probably more closely approximates the death rate from these injuries in an unselected pediatric population than do statistics from tertiary care hospitals. There was no significant relationship between age and outcome in this age group, but mass lesions and uncontrolled intracranial hypertension adversely affected outcome. Diffuse cerebral swelling was commonly seen on computerized tomography scans, and generally was associated with a satisfactory outcome (75%). Two of 13 deaths were considered preventable, emphasizing the narrow therapeutic safety margin and extreme care required in treating these patients.

The University of Toronto head injury treatment study: a prospective, randomized comparison of pentobarbital and mannitol

Fifty-nine patients were treated in a prospective, randomized comparison of pentobarbital and mannitol for the control of intracranial hypertension resulting from head injury. Patients with elevated intracranial pressure (ICP) after evacuation of intracranial hematomas were randomized to one of two treatment groups; mannitol initially or pentobarbital initially, followed by the second drug as required by further elevation of ICP. Similarly, patients with raised ICP but without hematomas requiring evacuation were randomly assigned to two treatment groups in an identical paradigm. Those with ICP elevation and no hematoma treated with pentobarbital as initial therapy had a 77% mortality compared to a 41% mortality for those with mannitol as initial treatment. Patients with evacuated hematomas had mortalities of 40% and 43% (no significant difference) for pentobarbital and mannitol respectively. In both no-hematoma and hematoma streams pentobarbital was less effective than mannitol for control of raised ICP. Multivariable statistical analysis indicates that pentobarbital coma is not better than mannitol for the treatment of intracranial hypertension and may be harmful in no-hematoma patients with intracranial hypertension after head injury.

Predicting outcome from closed head injury by early assessment of trauma severity

The relationship between severity of head injury and outcome was studied in 96 patients. Severity was assessed based on the level of coma and presence of mass lesion, hemiparesis, skull fracture, and pupil abnormality. Outcome was assessed using the Wechsler Adult Intelligence Scale, the Halstead-Reitan neuropsychological battery, and the Glasgow Outcome Scale. The relationship between assessment of severity of trauma and the outcome measurements was calculated by multiple regression analysis. Results indicate that coma grade and estimates of premorbid intelligence quotient (IQ) served best to predict IQ as assessed after the injury. The combination of coma grade, mass lesion, and skull fracture were important predictors of the Halstead Impairment Index. Coma grade and pupil abnormality predicted the Glasgow Outcome Scale. Low to moderate relationships were found between the predictor variables and the measurement of IQ and the Glasgow Outcome Scale; multiple regression coefficients were 0.63 and 0.61, respectively. The relationship between measurement of trauma severity and the Halstead Impairment Index was also low (R = 0.37).

Megadose corticosteroid therapy following experimental traumatic spinal injury

Corticosteroids are frequently used in the treatment of spinal trauma, although neither experimental nor clinical evidence to support their use is persuasive. Recently there have been claims that extremely high doses ("megadoses") of corticosteroids (equivalent to 15 to 30 mg/kg of methylprednisolone) improve neurological recovery compared to results with traditional steroid doses. The authors have compared the effect of megadose dexamethasone and methylprednisolone therapy to that of saline treatment following traumatic cervical spinal injury in the cat. During 6 weeks postinjury, neurological recovery did not differ significantly in corticosteroid-treated and saline-treated animals. Moreover, histopathological changes in the spinal cord were similar in methylprednisolone- and saline-treated cats. Corticosteroid-treated animals had a higher mortality rate than did control animals, with the predominant cause of death being neurogenic pulmonary edema. It is concluded that megadose corticosteroid treatment does not improve neurological recovery in this experimental model of spinal injury, and is associated with increased mortality.

Some inquiries in neuroanesthesia and neurological supportive care

Complications of performing neurosurgery in the sitting position have been well defined, and include cardiac and respiratory effects, air embolism, and pneumocephalus. Prophylactic measures and early diagnosis allow prompt therapy with minimal residual sequelae. All anesthetic agents and techniques alter the intracranial dynamics. A clear understanding of drug effects and the pathology involved allow a rational choice of anesthetic management to maximize the potential for a good outcome. Patients with cerebrovascular disorders frequently have multisystem disease, and careful preanesthetic assessment and preparation ensure a more stable intraoperative and postoperative course. Many chemical and mechanical reactions follow an ischemic hypoxic insult, but appropriate therapeutic intervention and early establishment of cardiorespiratory support measures have shown promise in improving the neurological outcome in these patients.

Pharmacologic management of acute intracranial hypertension

Acute intracranial hypertension requires aggressive treatment with physiologic and pharmacologic measures guided by intracranial pressure monitoring devices. Therapy involves the use of diuretics, corticosteroids, and barbiturates in combination with hyperventilation, ventricular drainage, and general supportive measures. This review focuses on the pathophysiology of increased intracranial pressure and the pharmacologic agents used in its management.

Recovery from severe closed head injuries: repeat testings with the Halstead-Reitan Neuropsychological Battery

Evaluated 15 adult patients who were suffering severe, coma-producing closed head injuries for neuropsychological and intellectual impairment with the Halstead-Reitan Neuropsychological Battery and the Wechsler Adult Intelligence Scale. All Ss were tested shortly after the time of their accidents and were reevaluated at approximately 1 year posttrauma to document residual deficits and rate of recovery. A group of 15 neurologically normal control Ss, matched for age, education, and sex, received the same battery of psychological tests. Although the brain-injured group demonstrated improvement on essentially all of the dependent measures from first testing to second, comparisons made with the control group revealed numerous areas of residual impairment, which suggests only partial recovery during the first year posttrauma.

Comparison of outcome in two series of patients with severe head injuries

A comparison is made between the outcome distributions of two Dutch series of patients with severe head injuries. Both series are taken from the same study and cover the same period (1974 to 1977). There is a large difference in survival rate between the series: 45% versus 63%. The authors present a possible method for assessing the influence of differences in initial severity of injury on outcome. It is estimated that, of the 18% difference in survival rate, 10.5% is due to differences in severity of injury on admission. The remaining 7.5% difference in survival rate is not explained, but may have been caused by unmeasured variations in the initial determination of severity of injury or by differences in effectiveness of management. The higher survival rate was achieved at the center with the more conservative management regimen. An evaluation of recent literature suggests that reports that do not find aspects of "aggressive" management beneficial are more reliable in comparing series than are those that claim improved outcome after aggressive therapy.

Severe head injury managed without intracranial pressure monitoring

A prospective series of 100 consecutive severe head injuries is presented. There were 34 deaths. Intracranial pressure (ICP) was not monitored in this series, and it is suggested that the outcome compares favorably with series in which ICP monitoring was performed. Early evacuation of life-threatening intracranial hematoma and airway control remain essentials of treatment of severe head injury.

Intensive management of severe head injuries. A scheme of intensive management of severe head injuries

Seventy-six severely head-injured patients, 67% of whom had Glasgow Coma scores of five or less on admission, were managed according to an intensive treatment regime which included controlled hyperventilation (under full muscular paralysis), high-dose steroids, dehydrating agents, diuretics and hypnotics (Althesin and thiopentone). Intracranial pressure (ICP) was measured throughout the period of controlled ventilation. Treatment was directed to keeping the mean ICP below 25-30 mmHg and to the prevention of increases in ICP during chest physiotherapy and other noxious stimulation. Six months after injury 46% of patients had died and 4% were vegetative survivors, whilst 43% had made a good recovery or were only moderately disabled. Features associated with worse than average prognosis were: low coma score, pupillary abnormalities, respiratory dysrhythmia and ICP greater than 30 mmHg. Spontaneous hyperventilation was a relatively good initial feature. These results support the employment of intensive care in severely head-injured patients, particularly those with diffuse brain injury.

Megadose steroids in severe head injury. Results of a prospective double-blind clinical trial

A prospective double-blind clinical trial was performed on 161 patients to determine the effectiveness of high-dose steroid therapy in patients admitted comatose after a non-missile-related head injury. Patients were randomized into a high-dose dexamethasone phosphate group and a placebo group. The initial dose of 100 mg of dexamethasone was administered within 6 hours of the accident. For statistical analysis, a sequential test was chosen, using survival at 1 month as a basic criterion of effectiveness. No significant difference was found in the 1-month survival rate or in the distribution of outcome after 6 months, either within the group as a whole, or in subgroups with varying severity of brain damage on admission. The authors conclude that dexamethasone in high doses has no statistically significant effect on morbidity or mortality in head-injured patients who are comatose on admission.

Enzymatic changes in serum and cerebrospinal fluid in neurological injury

✓ Enzymatic determinations in serum and cerebrospinal fluid (CSF) of creatine phosphokinase (CPK) and its isoenzymes, lactic dehydrogenase (LDH) and its isoenzymes, and glutamic oxaloacetic transaminase (GOT) were performed on patients with closed head injury with Glasgow Coma Scale (GCS) scores of 3 to 15. The purpose of the work was to study the usefulness of these determinations as a biochemical index of brain injury. Detailed analysis of serum determinations on 139 patients demonstrated a prognostic correlation for only the CPK1 isoenzyme. The presence of the CPK1 isoenzyme correlated with the degree of head injury (as indexed by the GCS) and with the ultimate outcome. Although the presence of the CPK1 isoenzyme was a foreboding sign, it was not consistently present even with severe head injury, and its presence was not invariably associated with poor outcome. Therefore, serum enzymatic determinations have an inadequate sensitivity and specificity for use as an index of neurological trauma.

Fifty-seven patients had CSF enzymatic determinations, and each of the enzymes studied was correlated directly with GCS and with the ultimate outcome. Within the subgroup of severely head-injured patients with a GCS score of 3 to 7, only the CPK1 and LDH1 isoenzymes correlated with the degree of head trauma and outcome. The CPK1 isoenzymes were not detectable in CSF from control patients, but were invariably present following head trauma. These CPK1 isoenzymes in the CSF were particularly useful in that they appeared in the acute course and were subsequently absent unless secondary injury to the brain occurred causing additional neurological damage. Secondary injuries due to delayed hemorrhage, infarction, hypoxia, or pathological evaluations of intracranial pressure were readily detected. The LDH1 isoenzyme is present in the CSF from normal patients and does elevate with neurological trauma; these LDH1 isoenzymes appear to be elevated for a period of weeks to months following injury and thus are less useful in detecting secondary injuries. An attempt was made to investigate the effect of Decadron (dexamethasone) on these enzymatic changes, but no significant effect was identified. Also noted in this study was the presence of CPK1 isoenzymes in the CSF of patients with gunshot wounds to the head, spinal cord injuries, and herniation syndromes. It is concluded, therefore, that CPK1 isoenzymes in the CSF appear to be a specific marker for neurological trauma, and may be of value both in clinical practice and in clinical investigations.

Computerized tomography (CT) in patients with head injuries. Assessment of outcome based upon initial clinical findings and initial CT scans

In this study, which comprises 144 consecutive head injuries, the initial clinical assessment and the findings of the initial CT scan are related to the outcome. The mortality is related to the patient's level of consciousness and pupillary light reflex on admission. The disability rate (= number of disabled/number of survivors) was independent of the level of consciousness but closely related to pupillary light reaction. Diminished and obliterated basal cisterns were bad prognostic signs, with a mortality rate of 66% in the latter group. Both disability and mortality increase with the number of different lesion types.

Problems in design of stroke treatment trials

Critical evaluation of the literature was use to identify remediable flaws in the design of clinical trials of stroke treatment. Trials of dexamethasone, dextran, and glycerol were reviewed. Available studies have in common major weaknesses in case selection (failure to exclude arteriolar strokes due to hemorrhage or lacunar infarction), and failure to estimate required sample size. Problems of case selection can be avoided with computerized tomography; the sample size required to show superiority of active treatment over placebo can be estimated using standard formulas. Prognostic stratification is suggested as a method of overcoming problems of unbalanced allocation. Further studies with improved design are required to evaluate the prospects for medical limitation of cerebral infarct size.

Corticosteroids in treatment of serious decompression sickness

Although high-dose corticosteroids have been widely recommended as an adjunctive measure in the treatment of serious decompression sickness, there are few objective data to support their efficacy in this disease. An unusual case of neurological decompression sickness which seemed to demonstrate a therapeutic response to steroids independent of recompression is presented. The various manifestations of decompression sickness and the effectiveness of delayed treatment are discussed.

Computerized tomography (CT) in patients with head injuries. Relation between CT scans and clinical findings in 96 patients

In a retrospective series of 144 patients with cranial trauma admitted to the Department of Neurosurgery, 96 were initially examined by CT. The initial clinical assessment, operative findings, if any, and the clinical course were compared to the results of the primary CT scan. In patients presenting lateralizing deficits, 49% had lesions on the expected side, and 23% on the opposite side. Thirty-one per cent of brain stem affected patients had a supratentorial mass lesion requiring craniotomy. Three decerebrate patients who had died had an initially normal CT scan. Thirty craniotomies were performed on the basis of the CT scan, and six cases deviated from the expected, but no case showed a false positive indication for surgery. The final diagnosis was in accordance with the initial clinical diagnosis, and with the initial CT scan in 44% and 84%, respectively, of all cases.

Steroids in severe head injury: A prospective randomized clinical trial

This is a prospective randomized study of the efficacy of steroid therapy in patients with severe head injury. One hundred patients were randomized into two equal groups: the steroid group received 5 mg/kg/day of methylprednisolone, and the nonsteroid group received no drug. The groups were similar in their clinical features. All patients received a standardized therapeutic regimen. The patients were also classified as early responders or nonresponders to the overall treatment protocol without regard to steroid administration, on the basis of change in Glasgow Coma Scale score during the first 3 days of admission. There was no statistically significant difference in the outcome of the steroid and nonsteroid group at 6 months. Of the responders who were on steroids, 74% had good outcomes or were disabled, compared with 56% of the responders who did not receive steroids. In the nonresponder group, the patients on steroids were actually associated with a worse outcome than those who did not receive steroids: 75% of the nonresponders who received steroids were dead or vegetative, compared to 56% of those who were not receiving steroids. The data suggest that: 1) the effect of steroids may be different for different patient groups; 2) in order to identify these patients, a sensitive coma scale is needed; and 3) a rational approach to steroid therapy in head-injured patients may be to start all patients on steroids, but to discontinue their use in patients identified as not benefiting from steroid therapy.

Cerebellar stimulation for chronic extensor-flexor rigidity and opisthotonus secondary to hypoxia. Report of two cases

Two patients with chronic hypertonus (in a decerebrate state) as a result of hypoxia are described. Long-term cerebellar stimulation markedly modified their extraordinarily severe extensor-flexor rigidity phenomena that had resulted in chronic opisthotonus.

Treatment for severe head injury

Difficulties in establishing the value of certain treatments for head injury are reviewed. An analysis of 1000 severely head injured patients, managed by varying methods in three different countries, showed that certain treatments were more often used in the most severely injured patients. Even when the severity of injury was taken account of, it appeared that the use of steroids and tracheostomy did not affect outcome; but that patients undergoing mechanical ventilation had outcomes which were worse than expected. The value of treatments proposed for severe head injury needs rigorous scrutiny.