Indications for use of corticosteroids - cerebral oedema from metastatic disease

Role

Corticosteroids rapidly reduce vasogenic oedema surrounding brain metastases, providing prompt symptomatic relief of raised intracranial pressure symptoms (headache, nausea, focal neurological deficit) while definitive treatment (radiotherapy, surgery) is arranged
A common indication in patients with known or newly diagnosed brain metastases, particularly when symptomatic at presentation or with significant oedema on imaging

Brain metastases disrupt the blood-brain barrier locally, causing vasogenic oedema in the surrounding white matter - corticosteroids stabilise the blood-brain barrier and reduce capillary permeability, reducing oedema (and therefore mass effect) rapidly, often within hours, well before any effect on the tumour itself

Dexamethasone is the corticosteroid of choice (low mineralocorticoid activity, long half-life allowing once- or twice-daily dosing, and high potency for a relatively small tablet/volume burden)
Dose is titrated to the clinical response and symptom severity - higher doses for significant mass effect/reduced consciousness, with a view to tapering to the lowest effective dose once symptoms are controlled and definitive treatment is underway

Response is often rapid (hours to 1-2 days) - a lack of expected improvement should prompt reconsideration of the diagnosis or urgent escalation (e.g. for surgical decompression) rather than simply increasing the steroid dose indefinitely
Taper once definitive treatment (radiotherapy/surgery) has had its effect, balancing symptom control against the cumulative side effects of prolonged high-dose corticosteroids (myopathy, hyperglycaemia, immunosuppression, mood disturbance)

Brain metastases (lung, breast, melanoma most common primaries), raised intracranial pressure, seizures (a separate but related complication needing its own management)

Corticosteroids treat the oedema, not the tumour itself - they are a bridge to definitive treatment (radiotherapy/surgery) or, in a purely palliative context, a symptom-control measure, and should not be mistaken for disease-modifying therapy

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