Can steroids be given in Subarachnoid Hemorrhage (SAH)?

Steroids in Subarachnoid Hemorrhage Management

Steroids are not recommended for routine use in subarachnoid hemorrhage (SAH) as there is insufficient evidence supporting their benefit for improving mortality or neurological outcomes. 1

Evidence Assessment

Current Guideline Recommendations

The American Heart Association/American Stroke Association guidelines do not support routine steroid administration in SAH management. The 2020 guidelines on treatment of spontaneous SAH specifically note that "drugs targeting inflammation, such as glucocorticoid steroids, have not been sufficiently studied in aSAH to assess their safety and efficacy" 1.

Similarly, the 2012 AHA/ASA guidelines stated that "the routine long-term use of anticonvulsants is not recommended" but did not specifically endorse steroid use for any indication in SAH 1.

Specific Clinical Scenarios

For Cerebral Edema

While steroids are commonly used for cerebral edema in other neurological conditions, their efficacy in SAH-related edema lacks strong evidence:

• A Cochrane systematic review found no evidence of beneficial or adverse effects of corticosteroids in patients with SAH 2
• Confidence intervals were wide and included clinically significant effects in both directions, making definitive conclusions impossible 2

For Systemic Inflammatory Response

• SAH is associated with a systemic inflammatory response syndrome in approximately 50% of patients 1
• While inflammation mediated by interleukin-1 may contribute to brain injury after SAH, glucocorticoid steroids have not been adequately studied 1
• A phase 2 RCT of anakinra (an interleukin-1 receptor antagonist) showed inhibition of systemic inflammation with a favorable safety profile, but steroids themselves lack similar evidence 1

For Sodium and Fluid Management

• Some evidence suggests potential benefit of corticosteroids with mineralocorticoid activity (hydrocortisone or fludrocortisone) for maintaining sodium and volume homeostasis in SAH patients 3
• These agents may decrease natriuretic diuresis and reduce the incidence of hypovolemia 3
• However, this specific application has not been incorporated into major guidelines

Potential Risks of Steroid Use in SAH

Steroid administration in SAH patients carries several potential risks:

• Increased risk of infections, particularly urinary tract infections 4
• Potential for hyperglycemia, which can worsen neurological outcomes
• Gastrointestinal complications (though one retrospective study found similar rates of GI bleeding between steroid and non-steroid groups) 4

Current Management Priorities in SAH

Instead of steroids, current guidelines emphasize:

1. Early aneurysm obliteration (within 24 hours) 5
2. Blood pressure control (systolic BP <160 mmHg) 5
3. Nimodipine administration (60 mg orally every 4 hours for 21 days) as the only evidence-based medical intervention for improving neurological outcomes 5, 6
4. Maintenance of euvolemia rather than hypervolemia 5
5. Monitoring for and treating complications such as hydrocephalus, vasospasm, and delayed cerebral ischemia 5

Conclusion

Based on current evidence and guidelines, steroids should not be routinely administered for the management of SAH. The only evidence-based pharmacological intervention for improving outcomes in SAH is nimodipine. For specific issues like hyponatremia or fluid balance, targeted interventions with mineralocorticoids might be considered, but larger trials are needed to confirm their efficacy and safety.