What is the role of steroids in managing a patient with an intracranial (within the skull) bleed?

Steroids Should NOT Be Used Routinely in Acute Intracranial Hemorrhage

Corticosteroids have no proven benefit for acute spontaneous intracerebral hemorrhage and should be avoided in routine management. The evidence consistently demonstrates no improvement in mortality or functional outcomes, with potential for increased complications.

Evidence Against Routine Steroid Use

Spontaneous Intracerebral Hemorrhage (ICH)

• Steroids provide no clinical benefit in primary ICH. A prospective study of 129 patients showed no significant difference in clinical evolution between dexamethasone-treated, methylprednisolone-treated, and non-steroid groups 1
• In putamino-capsular bleedings specifically, the non-steroid-treated group performed significantly better than steroid-treated patients 1
• Current acute ICH management guidelines do not recommend corticosteroids, as there is no evidence supporting their routine use 2

Traumatic Intracranial Hemorrhage

• The evidence base does not support routine steroid administration for traumatic intracranial bleeding 3
• Management should focus on hemostatic therapies and physiological optimization rather than corticosteroid administration 2

Limited Exception: Brain Metastases with Hemorrhage

The only scenario where steroids have a defined role is in patients with brain metastases who develop symptomatic raised intracranial pressure:

• Use the lowest effective dose for the shortest duration possible 3
• Steroids should only be considered in symptomatic patients with brain metastases, not for routine intracranial hemorrhage 3
• When steroids are used for more than a few weeks in this population, consider Pneumocystis jirovecii prophylaxis with trimethoprim-sulfamethoxazole if additional immunosuppressive therapy is administered 3

Potential Role in Chronic Subdural Hematoma

• Steroids may have a limited role in chronic subdural hematoma (not acute bleeding), particularly in select patients 4
• Female patients, those with less midline shift, and lower density hematomas respond better to steroid treatment 4
• This represents a distinct clinical entity from acute intracranial hemorrhage and should not be extrapolated to acute bleeding scenarios 4

Complications of Steroid Use

When steroids are inappropriately used in intracranial hemorrhage patients, expect:

• Increased risk of urinary tract infections (14.0% vs 4.7% in controls) 5
• Hyperglycemia requiring monitoring 5, 4
• Gastritis and gastrointestinal complications 5, 4
• No reduction in adverse outcomes despite these risks 1

Clinical Algorithm for Decision-Making

For acute spontaneous ICH or traumatic intracranial hemorrhage:

• Do NOT administer corticosteroids 2, 1
• Focus on blood pressure control, coagulopathy reversal, and physiological optimization 2
• Consider hemostatic therapies based on timing and coagulation status 3

For brain metastases with hemorrhage and symptomatic mass effect:

• Consider low-dose dexamethasone only if clinically symptomatic from raised intracranial pressure 3
• Taper as quickly as clinically feasible 3

For chronic subdural hematoma (>3 weeks old):

• May consider trial of dexamethasone in select patients (female, minimal midline shift, lower density) 4
• This is a separate clinical entity from acute hemorrhage 4

Common Pitfalls to Avoid

• Do not reflexively prescribe steroids for "cerebral edema" in acute ICH—this outdated practice lacks evidence and may worsen outcomes 1
• Do not confuse chronic subdural hematoma management (where steroids may have limited utility) with acute intracranial bleeding (where they do not) 4, 1
• Do not use steroids as a substitute for definitive management of raised intracranial pressure—consider surgical intervention, osmotic therapy, or other evidence-based approaches instead 2