Acute Treatment of Cerebral Edema in Neurocritical Care Patients
Publication Date: May 15, 2015
Last Updated: November 21, 2022
Recommendations
Treatment of Cerebral Edema in Patients with Subarachnoid Hemorrhage
We suggest using symptom-based bolus dosing of hypertonic sodium solutions rather than sodium target-based dosing for the management of ICP or cerebral edema in patients with SAH. (Conditional, Very Low)
316789
Due to insufficient evidence, we cannot recommend a specifc dosing strategy for HTS to improve neurological outcomes in patients with SAH. (, )
316789
Treatment of Cerebral Edema in Patients with Traumatic Brain Injury
We suggest using hypertonic sodium solutions over mannitol for the initial management of elevated ICP or cerebral edema in patients with TBI (conditional recommendation, low-quality evidence). We suggest that neither HTS nor mannitol be used with the expectation for improving neurological outcomes in patients with TBI. (Conditional, Low)
316789
We suggest that the use of mannitol is an efective alternative in patients with TBI unable to receive hypertonic sodium solutions. (Conditional, Low)
316789
We recommend against the use of hypertonic sodium solutions in the pre-hospital setting to specifcally improve neurological outcomes for patients with TBI. (Strong, Moderate)
316789
We suggest against the use of mannitol in the pre-hospital setting to improve neurological outcomes for patients with TBI. (Conditional, Very Low)
316789
Treatment of Cerebral Edema in Patients with Acute Ischemic Stroke
We suggest using either hypertonic sodium solutions or mannitol for the initial management of ICP or cerebral edema in patients with acute ischemic stroke. (Conditional, Low)
There is insufcient evidence to recommend either hypertonic saline or mannitol for improving neurological outcomes in patients with acute ischemic stroke.
316789
We suggest that clinicians consider administration of hypertonic sodium solutions for management of ICP or cerebral edema in patients with acute ischemic stroke who do not have an adequate response to mannitol. (Conditional, Low)
316789
We suggest against the use of prophylactic scheduled mannitol in acute ischemic stroke due to the potential for harm. (Conditional, Low)
316789
Treatment of Cerebral Edema in Patients with Intracerebral Hemorrhage
Recommendations for Hyperosmolar Therapy
We suggest using hypertonic sodium solutions over mannitol for the management of ICP or cerebral edema in patients with intracerebral hemorrhage. (Conditional, Very Low)
316789
We suggest that either symptom-based bolus dosing or using a targeted sodium concentration is appropriate hypertonic sodium solution administration strategy for the management of elevated ICP or cerebral edema in patients with intracerebral hemorrhage. (Conditional, Very Low)
316789
Recommendations for Corticosteroids in Patients with Intracerebral Hemorrhage
We recommend against the use of corticosteroids to improve neurological outcome in patients with intracerebral hemorrhage due to the potential for increased mortality and infectious complications. (Strong, Moderate)
316789
Treatment of Cerebral Edema in Patients with Bacterial Meningitis
We recommend dexamethasone 10 mg intravenous every 6 h for 4 days to reduce neurological sequelae (primarily hearing loss) in patients with community-acquired bacterial meningitis. (Strong, Moderate)
316789
We suggest dexamethasone 0.15 mg/kg intravenous every 6 h for 4 days as an alternative dose for patients with low body weight or high risk of corticosteroid adverse effects. (, )
(good practice statement)
316789
We recommend administering dexamethasone before or with the frst dose of antibiotic in patients with bacterial meningitis. (Strong, Moderate)
316789
We recommend use of corticosteroids to reduce mortality in patients with tuberculosis meningitis. (Strong, Moderate)
We cannot make a recommendation for one specifc corticosteroid or dose in patients with TB meningitis due to the inconsistency of agents and doses evaluated in the literature.
316789
We suggest that treatment with corticosteroids should be continued for two or more weeks in patients with tuberculosis meningitis. (Conditional, Low)
316789
There is insufficient evidence to determine whether hypertonic sodium solutions or mannitol is more efective to reduce ICP or cerebral edema in patients with community-acquired bacterial meningitis. (, )
316789
Treatment of Cerebral Edema in Patients with Hepatic Encephalopathy
We suggest using either hypertonic sodium solutions or mannitol for the management of ICP or cerebral edema in patients with hepatic encephalopathy. (Conditional, Very Low)
316789
There is insufficient evidence to determine whether either hyperosmolar therapy or ammonia-lowering therapy improves neurological outcomes in patients with hepatic encephalopathy. (, )
316789
Hyperosmolar Therapy Safety and Infusion Considerations
We suggest using osmolar gap over serum osmolarity thresholds during treatment with mannitol to monitor for the risk of AKI. (Conditional, Very Low)
316789
There is insufcient evidence to recommend a cutoff value for osmolar gap when evaluating for the risk of acute kidney injury. (, )
316789
Renal function measures should be monitored closely in patients receiving mannitol due to the risk of AKI with hyperosmolar therapy. (, )
(good practice statement)
316789
Recommendations for Assessing the Risk of Toxicity (Acute Kidney Injury or Unwanted Acidosis) After Hypertonic Sodium Solution Administration
We suggest that severe hypernatremia and hyperchloremia during treatment with hypertonic sodium solutions should be avoided due to the association with acute kidney injury. (Conditional, Low)
316789
An upper serum sodium range of 155–160 mEq/L and a serum chloride range of 110–115 mEq/L may be reasonable to decrease the risk of acute kidney injury. (Conditional, Very Low)
316789
Clinicians should routinely monitor both sodium and chloride serum concentrations to assess risk of AKI related to elevated concentrations. (, )
(good practice statement)
316789
Renal function should be monitored closely in patients receiving hypertonic sodium solutions due to the risk of AKI with hyperosmolar therapy. (, )
(good practice statement)
316789
Recommendations for the Optimal Administration Method of Hypertonic Sodium Solution
There is insufcient evidence to support use of a continuous infusion of HTS targeting a serum sodium goal for the purpose of improving neurological outcomes. (, )
316789
Due to insufcient evidence, we cannot recommend a specifc dosing strategy for HTS to improve neurological outcomes in patients with cerebral edema. (, )
316789
Clinicians should avoid hyponatremia in patients with severe neurological injury due to the risk of exacerbating cerebral edema. (, )
(good practice statement)
316789
Non‑pharmacologic Treatment of Cerebral Edema and Elevated Intracranial Pressure
We suggest that elevating the head of the bed to 30 degrees (but no greater than 45 degrees) be used as a benefcial adjunct to reduce intracranial pressure. (Conditional, Very Low)
316789
We recommend that brief episodes of hyperventilation can be used for patients with acute elevations in intracranial pressure. (Strong, Very Low)
316789
We suggest that the use of CSF diversion be considered as a benefcial adjunct to reduce intracranial pressure. (Conditional, Very Low)
316789
While non-pharmacological interventions may be efective for acute elevations in intracranial pressure, there is insufficient evidence that non-pharmacological interventions are efective for the treatment of any specifc physiological changes that produce brain swelling related to cerebral edema. (, )
316789
Recommendation Grading
Overview
Title
Acute Treatment of Cerebral Edema in Neurocritical Care Patients
Authoring Organization
Neurocritical Care Society
Publication Month/Year
May 15, 2015
Last Updated Month/Year
January 10, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Emergency care, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment
Diseases/Conditions (MeSH)
D001929 - Brain Edema, D004487 - Edema
Keywords
neurocritical, hyperosmolar therapy, cerebral edema, elevated intracranial pressure, neurological injury
Source Citation
Cook AM, Morgan Jones G, Hawryluk GWJ, Mailloux P, McLaughlin D, Papangelou A, Samuel S, Tokumaru S, Venkatasubramanian C, Zacko C, Zimmermann LL, Hirsch K, Shutter L. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients. Neurocrit Care. 2020 Jun;32(3):647-666. doi: 10.1007/s12028-020-00959-7. PMID: 32227294; PMCID: PMC7272487.