Corticosteroid Use in Acute Ischemic Stroke

General Contraindication for Acute Stroke

The American Heart Association/American Stroke Association guidelines state that corticosteroids should not be administered for the treatment of cerebral edema and increased intracranial pressure complicating ischemic stroke, due to the lack of mortality or functional benefit and increased risk of harm (Class III: Harm recommendation, Level of Evidence A) 1, 2
Corticosteroids increase the risk of infectious complications without providing therapeutic benefit in acute stroke, according to the American Heart Association/American Stroke Association guidelines 1, 3

The American College of Rheumatology recommends immediate initiation of oral high-dose glucocorticoids for giant cell arteritis to reduce recurrent stroke risk and prevent permanent blindness (Class I, Level of Evidence B-NR) 4, 5
The American Heart Association/American Stroke Association guidelines suggest induction therapy with glucocorticoids and/or immunosuppressants followed by long-term maintenance therapy for primary CNS angiitis (Class IIa, Level of Evidence B-NR) 4, 5, 6
The American College of Rheumatology recommends steroids plus adjunctive therapy (methotrexate, azathioprine, or leflunomide) for Takayasu arteritis, with slow taper to ≤5 mg/day after 1 year 4, 6

For a patient with recent stroke, the American Heart Association/American Stroke Association guidelines recommend determining stroke etiology immediately and not giving corticosteroids for standard atherosclerotic/cardioembolic stroke 1, 2, 3
If giant cell arteritis is suspected, the American College of Rheumatology recommends starting high-dose glucocorticoids immediately 4, 5
If primary CNS vasculitis is confirmed, the American Heart Association/American Stroke Association guidelines suggest starting glucocorticoids with immunosuppressants 4, 6

The American Heart Association/American Stroke Association guidelines advise against administering corticosteroids for routine acute ischemic stroke management, even with significant cerebral edema, as they increase infection risk without benefit 1, 2, 3
The American College of Rheumatology recommends not delaying giant cell arteritis treatment waiting for biopsy confirmation if clinical suspicion is high, as immediate glucocorticoid therapy is critical to prevent blindness and recurrent stroke 4, 5