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December 22, 1989, Vol 262, No. 24 >
ARTICLE | December 22, 1989

Glucocorticoid Treatment Does Not Improve Neurological Recovery Following Cardiac Arrest FREE

Michael Jastremski, MD; Kim Sutton-Tyrrell, DrPH; Per Vaagenes, MD; Norman Abramson, MD; Darell Heiselman, DO; Peter Safar, MD
[+] Author Affiliations

Reprint requests to Department of Critical Care and Emergency Medicine, State University of New York Health Science Center, 750 E Adams St, Syracuse, NY 13210 (Dr Jastremski).


JAMA. 1989;262(24):3427-3430. doi:10.1001/jama.1989.03430240063030
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References

Glucocorticoids are commonly given to patients with global brain ischemia, although their efficacy has not been proved. The database of the Brain Resuscitation Clinical Trial I, a multi-institutional study designed to evaluate the effect of thiopental sodium therapy on neurological outcome following brain ischemia, was used for a retrospective review of the effects of glucocorticoid treatment on neurological outcome after global brain ischemia. This study included 262 initially comatose cardiac arrest survivors who made no purposeful response to pain after restoration of spontaneous circulation. The standard treatment protocol left glucocorticoid therapy to the discretion of the hospital investigators. This resulted in four patient groups that received either no, low, medium, or high doses of glucocorticoids in the first 8 hours after arrest. Neurological outcome was scored using a modification of the Glasgow Cerebral Performance Category Scale. None of the steroid regimens statistically improved mean group survival rate or neurological recovery rate over that observed in the group that did not receive steroids. The routine clinical practice of administrating glucocorticoids after global brain ischemia may be associated with serious complications and is not justified.

(JAMA. 1989;262:3427-3430)

REFERENCES

1 +
Wiles CM.  Steroids in neurology . Br J Hosp Med. 1982;;28:308-322.
2 +
Safar P.  Steroids in brain insults (a partial review) . In: Villazon SA, Llamosa JLB, Hervella PL, et al, eds. Critical Care Medicine . Princeton, NJ: Excerpta Medica; 1980;:164-173.
3 +
Safar P, Grenvik A, Abramson N, et al, eds.  International Resuscitation Research Symposium on the Reversibility of Clinical Death, May 1987 . Crit Care Med . 1988;;16:919-1084.
4 +
Maxwell RE, Long DM, French LA.  The clinical effects of a synthetic glucocorticoid used for brain edema in the practice of neurosurgery . In: Reulen HJ, Schurmann K, eds. Steroids and Brain Edema . New York, NY: Springer-Verlag NY Inc; 1972;:219-232.
5 +
Klatzo I.  Neuropathological aspects of brain edema . J Neuropathol Exp Neurol. 1967;;26:1-14.
6 +
Anderson DC, Crawford RE.  Corticosteroids in ischemic stroke . Stroke. 1979;;10:68-71.
7 +
Katzman R, Clasen R, Klatzo I, et al.  Brain edema in stroke . Stroke. 1977;;8:512-540.
8 +
Katz L, Vaagenes P, Safar P, Diven W.  Brain enzyme changes as a marker of brain damage in rat cardiac arrest model: effects of corticosteroid therapy . Resuscitation. 1989;;17:39-53.
9 +
Gisvold SE, Safar P, Rao G, et al.  Multifaceted therapy after global brain ischemia in monkeys . Stroke. 1984;;15:803-812.
10 +
Katz L, Vaagenes P, Safar P, et al.  Brain resuscitative potential of methylprednisolone after asphyxial cardiac arrest in rats . Anesthesiology. 1985;;63:A1111. Abstract.
11 +
Sapolsky RM, Pulsinelli WA.  Glucocorticoids potentiate ischemic injury to neurons: therapeutic implications . Science. 1985;;299:1397-1400.
12 +
Brain Resuscitation Clinical Trial I Study Group.  Randomized clinical study of thiopental loading in comatose survivors of cardiac arrest . N Engl J Med. 1986;;314:397-403.
13 +
Brain Resuscitation Clinical Trial I Study Group.  A randomized clinical study of cardiopulmonary-cerebral resuscitation . Am J Emerg Med. 1986;;4:72-86.
14 +
Gottlieb AJ, Zamkoff KW, Jastremski MS, Scalzo A, Imboden KJ. The Whole Internist Catalog . Philadelphia, Pa: WB Saunders Co; 1980;:241.
15 +
Bone RC, Fisher CJ, Clemmer TP, et al.  A controlled clinical trial of high-dose methlyprednisolone in the treatment of severe sepsis and septic shock . N Engl J Med. 1987;;317:653-658.
16 +
Andrassy RJ, Dubois T.  Modified injury severity scale and concurrent steroid therapy: independent correlates of negative nitrogen balance in pediatric trauma . J Pediatr Surg. 1985;;20:799-802.
17 +
Dearden NM, Gibson JS, McDowall DG, Gibson RM, Cameron MM.  Effect of high-dose dexamethasone on outcome from severe head injury . J Neurosurg. 1986;;64:81-88.
18 +
Cooper PR, Moody S, Clark WK, et al.  Dexamethasone and severe head injury: a prospective double-blind study . J Neurosurg. 1979;;51:307-316.
19 +
Braakman R, Schouten HJ, Dishoeck MB, Minderhoud JM.  Megadose steroids in severe head in jury: results of a prospective double-blind clinical trial . J Neurosurg. 1983;;58:326-330.
20 +
Gudeman SK, Miller JD, Becker DP.  Failure of high-dose steroid therapy to influence intracranial pressure in patients with severe head injury . J Neurosurg. 1979;;51:301-306.
21 +
Saul TG, Ducker TB, Salcman M, Carro E.  Steroids in severe head injury: a prospective randomized clinical trial . J Neurosurg. 1981;;54:596-600.
22 +
Bauer RB, Tellez H.  Dexamethasone as treatment in cerebrovascular disease: a controlled study in acute cerebral infarction . Stroke. 1973;;4:547-555.
23 +
Gilsanz V, Rebollar JL, Buencuerpo J, Chantres MT.  Controlled trial of glycerol versus dexamethasone in the treatment of cerebral edema in acute cerebral infarction . Lancet . 1975;;1:1049-1051.
24 +
Mulley G, Wilcox RG, Mitchell JR.  Dexamethasone in acute stroke . Br Med J. 1978;;2:994-996.
25 +
Norris JW, Hachinski VC.  High dose steroid treatment in cerebral infarction . Br Med J. 1986;;292:21-23.
26 +
Poungvarin N, Bhoopat W, Viriyavejakul A, et al.  Effects of dexamethasone in primary supratentorial intracerebral hemorrhage . N Engl J Med. 1987;;316:1229-1233.
27 +
Grafton ST, Longstreth WT.  Steroids after cardiac arrest: a retrospective study with concurrent nonrandomized controls . Neurology . 1988;; 38:1315-1316.

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1 +
Wiles CM.  Steroids in neurology . Br J Hosp Med. 1982;;28:308-322.
2 +
Safar P.  Steroids in brain insults (a partial review) . In: Villazon SA, Llamosa JLB, Hervella PL, et al, eds. Critical Care Medicine . Princeton, NJ: Excerpta Medica; 1980;:164-173.
3 +
Safar P, Grenvik A, Abramson N, et al, eds.  International Resuscitation Research Symposium on the Reversibility of Clinical Death, May 1987 . Crit Care Med . 1988;;16:919-1084.
4 +
Maxwell RE, Long DM, French LA.  The clinical effects of a synthetic glucocorticoid used for brain edema in the practice of neurosurgery . In: Reulen HJ, Schurmann K, eds. Steroids and Brain Edema . New York, NY: Springer-Verlag NY Inc; 1972;:219-232.
5 +
Klatzo I.  Neuropathological aspects of brain edema . J Neuropathol Exp Neurol. 1967;;26:1-14.
6 +
Anderson DC, Crawford RE.  Corticosteroids in ischemic stroke . Stroke. 1979;;10:68-71.
7 +
Katzman R, Clasen R, Klatzo I, et al.  Brain edema in stroke . Stroke. 1977;;8:512-540.
8 +
Katz L, Vaagenes P, Safar P, Diven W.  Brain enzyme changes as a marker of brain damage in rat cardiac arrest model: effects of corticosteroid therapy . Resuscitation. 1989;;17:39-53.
9 +
Gisvold SE, Safar P, Rao G, et al.  Multifaceted therapy after global brain ischemia in monkeys . Stroke. 1984;;15:803-812.
10 +
Katz L, Vaagenes P, Safar P, et al.  Brain resuscitative potential of methylprednisolone after asphyxial cardiac arrest in rats . Anesthesiology. 1985;;63:A1111. Abstract.
11 +
Sapolsky RM, Pulsinelli WA.  Glucocorticoids potentiate ischemic injury to neurons: therapeutic implications . Science. 1985;;299:1397-1400.
12 +
Brain Resuscitation Clinical Trial I Study Group.  Randomized clinical study of thiopental loading in comatose survivors of cardiac arrest . N Engl J Med. 1986;;314:397-403.
13 +
Brain Resuscitation Clinical Trial I Study Group.  A randomized clinical study of cardiopulmonary-cerebral resuscitation . Am J Emerg Med. 1986;;4:72-86.
14 +
Gottlieb AJ, Zamkoff KW, Jastremski MS, Scalzo A, Imboden KJ. The Whole Internist Catalog . Philadelphia, Pa: WB Saunders Co; 1980;:241.
15 +
Bone RC, Fisher CJ, Clemmer TP, et al.  A controlled clinical trial of high-dose methlyprednisolone in the treatment of severe sepsis and septic shock . N Engl J Med. 1987;;317:653-658.
16 +
Andrassy RJ, Dubois T.  Modified injury severity scale and concurrent steroid therapy: independent correlates of negative nitrogen balance in pediatric trauma . J Pediatr Surg. 1985;;20:799-802.
17 +
Dearden NM, Gibson JS, McDowall DG, Gibson RM, Cameron MM.  Effect of high-dose dexamethasone on outcome from severe head injury . J Neurosurg. 1986;;64:81-88.
18 +
Cooper PR, Moody S, Clark WK, et al.  Dexamethasone and severe head injury: a prospective double-blind study . J Neurosurg. 1979;;51:307-316.
19 +
Braakman R, Schouten HJ, Dishoeck MB, Minderhoud JM.  Megadose steroids in severe head in jury: results of a prospective double-blind clinical trial . J Neurosurg. 1983;;58:326-330.
20 +
Gudeman SK, Miller JD, Becker DP.  Failure of high-dose steroid therapy to influence intracranial pressure in patients with severe head injury . J Neurosurg. 1979;;51:301-306.
21 +
Saul TG, Ducker TB, Salcman M, Carro E.  Steroids in severe head injury: a prospective randomized clinical trial . J Neurosurg. 1981;;54:596-600.
22 +
Bauer RB, Tellez H.  Dexamethasone as treatment in cerebrovascular disease: a controlled study in acute cerebral infarction . Stroke. 1973;;4:547-555.
23 +
Gilsanz V, Rebollar JL, Buencuerpo J, Chantres MT.  Controlled trial of glycerol versus dexamethasone in the treatment of cerebral edema in acute cerebral infarction . Lancet . 1975;;1:1049-1051.
24 +
Mulley G, Wilcox RG, Mitchell JR.  Dexamethasone in acute stroke . Br Med J. 1978;;2:994-996.
25 +
Norris JW, Hachinski VC.  High dose steroid treatment in cerebral infarction . Br Med J. 1986;;292:21-23.
26 +
Poungvarin N, Bhoopat W, Viriyavejakul A, et al.  Effects of dexamethasone in primary supratentorial intracerebral hemorrhage . N Engl J Med. 1987;;316:1229-1233.
27 +
Grafton ST, Longstreth WT.  Steroids after cardiac arrest: a retrospective study with concurrent nonrandomized controls . Neurology . 1988;; 38:1315-1316.

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