Is dexamethasone (corticosteroid) indicated in cases of intracranial bleeding?

Dexamethasone is Not Recommended in Intracranial Hemorrhage

Dexamethasone should not be used in patients with intracranial hemorrhage as it does not improve outcomes and may potentially increase mortality. 1

Evidence Against Dexamethasone Use in ICH

The European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage explicitly recommend against the use of dexamethasone in patients with acute intracerebral hemorrhage (ICH) outside of randomized controlled trials. 1

This recommendation is based on multiple randomized controlled trials that showed:

• No difference in the risk of death between dexamethasone and control groups (RR 1.14,95% CI 0.91-1.42)
• No beneficial effect on 6-month case fatality or poor outcomes after one month
• Potential for increased mortality with dexamethasone treatment (49% vs 23% at 21 days in one RCT) 1

A more recent meta-analysis from 2020 confirmed these findings, showing:

• No significant difference in mortality (RR 1.32,95% CI 0.99-1.76)
• No significant improvement in outcomes
• No significant difference in complications 2

Pathophysiological Considerations

While corticosteroids like dexamethasone are effective in reducing edema associated with brain tumors, this benefit does not translate to hemorrhagic stroke. The pathophysiology of edema in ICH differs from that in tumors:

• In ICH, edema is primarily related to blood breakdown products and inflammatory responses
• Dexamethasone does not effectively address the specific mechanisms of edema formation in ICH
• The potential risks (hyperglycemia, immunosuppression, gastrointestinal bleeding) outweigh any theoretical benefits

Special Considerations

Chronic Subdural Hematoma

For chronic subdural hematoma, which is different from acute ICH, a 2020 randomized trial showed that dexamethasone resulted in:

• Fewer favorable outcomes than placebo at 6 months
• More adverse events than placebo
• However, fewer repeat operations were needed in the dexamethasone group 3

Metabolic Effects

Dexamethasone administration during intracranial procedures can cause significant increases in blood glucose levels, which may be detrimental in the acute setting of ICH. 4 Hyperglycemia is associated with worse outcomes in stroke patients.

Current Management Approach for ICH

Instead of corticosteroids, the current management of ICH focuses on:

1. Acute stroke unit care - Reduces both death and dependency (high quality evidence, strong recommendation) 1
2. Blood pressure management - Intensive BP reduction (systolic target <140 mmHg) within 6 hours of onset is safe and may be superior to a target <180 mmHg 1
3. Reversal of coagulopathy if present (though evidence is limited) 1
4. Surgical intervention in selected cases (moderate evidence, weak recommendation) 1
5. Prevention of complications such as deep vein thrombosis using intermittent pneumatic compression 1

Conclusion

Based on the best available evidence, dexamethasone should not be administered to patients with intracranial hemorrhage. Current guidelines and multiple randomized trials demonstrate no benefit and potential harm with its use in this setting.