What is the role of dexamethasone in the management of acute ischemic stroke according to European and international practice guidelines?

Dexamethasone is Not Recommended in Acute Ischemic Stroke Management

Dexamethasone is not recommended for the management of acute ischemic stroke according to European and international practice guidelines. 1

Evidence from European Guidelines

• The European Stroke Organisation (ESO) explicitly recommends against the use of dexamethasone in patients with acute intracerebral hemorrhage outside of randomized controlled trials, based on moderate quality evidence 1
• While this recommendation specifically addresses hemorrhagic stroke, there are no positive recommendations for dexamethasone use in ischemic stroke in any of the major European guidelines 1
• The ESO guidelines for temperature management in acute ischemic stroke make no mention of dexamethasone as a treatment option, focusing instead on antipyretic medications for hyperthermia 1

Evidence from American Guidelines

• The American Heart Association/American Stroke Association (AHA/ASA) guidelines specifically state that "corticosteroids (in conventional or large doses) are not recommended for treatment of cerebral edema and increased intracranial pressure complicating ischemic stroke" with a Class III, Level of Evidence A recommendation 1
• This is one of the strongest negative recommendations in the guidelines, indicating clear evidence of harm or lack of benefit 1
• The AHA/ASA guidelines focus instead on other interventions for managing complications of acute ischemic stroke, such as decompressive surgery for malignant edema 1

Rationale for Not Using Dexamethasone

• Despite the theoretical benefits of reducing inflammation and edema, clinical trials have consistently failed to demonstrate efficacy of corticosteroids in improving outcomes in ischemic stroke 2, 3
• A prospective double-blind placebo-controlled trial of high-dose dexamethasone in stroke patients failed to demonstrate any benefit in improving mortality 2
• An older but well-designed randomized controlled trial of high-dose dexamethasone (480 mg over 12 days) in 113 patients with acute cerebral infarction found no significant difference in death rate or quality of survivorship compared to placebo 3

Potential Exceptions and Controversies

• One retrospective study from Crete suggested improved outcomes with intravenous dexamethasone in hemorrhagic stroke compared to patients managed without steroids in Boston 4
• However, this single retrospective study contradicts the findings of prospective trials and has not led to changes in international guidelines 4
• Spanish Neurological Society guidelines mention treatment of body temperature with antipyretic drugs if it rises above 37.5°C but do not recommend corticosteroids for this purpose 5

Current Recommended Approaches for Acute Ischemic Stroke

• Guidelines focus on reperfusion therapies (intravenous thrombolysis and endovascular thrombectomy) as the mainstay of acute ischemic stroke treatment 6
• Supportive care measures include:
  • Blood pressure management (treat only if >185/110 mmHg for patients receiving thrombolysis or >220/120 mmHg for others) 6
  • Temperature management with antipyretics for hyperthermia >38°C 6
  • Glucose management (treat hypoglycemia <60 mg/dL and hyperglycemia to achieve levels 140-180 mg/dL) 6
  • Early mobilization and rehabilitation 6

Conclusion for Clinical Practice

• For cerebral edema and increased intracranial pressure following ischemic stroke, guidelines recommend:
  • Decompressive surgery for malignant edema of the cerebral hemisphere 1
  • Placement of ventricular drain for acute hydrocephalus 1
  • Osmotherapy and hyperventilation for patients deteriorating due to increased intracranial pressure 6
• Corticosteroids, including dexamethasone, should not be used for the management of acute ischemic stroke or its complications 1