Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients

Neurocritical Care Society · 2020 · USA

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Authors: Aaron M Cook, G Morgan Jones, Gregory W J Hawryluk et al.
Title: Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients
Journal: Neurocritical Care, 2020
DOI: 10.1007/s12028-020-00959-7
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC7272487

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Recommendations

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 SAHconditional recommendation, very low-quality evidence

Rationale:

Due to insufficient evidence, we cannot recommend a specific dosing strategy for HTS to improve neurological outcomes in patients with SAH.

Recommendations

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 TBIconditional recommendation, low-quality evidence

Rationale:

We suggest that the use of mannitol is an effective alternative in patients with TBI unable to receive hypertonic sodium solutionsconditional recommendation, low-quality evidence
We recommend against the use of hypertonic sodium solutions in the pre-hospital setting to specifically improve neurological outcomes for patients with TBIstrong recommendation, moderate-quality evidence
We suggest against the use of mannitol in the pre-hospital setting to improve neurological outcomes for patients with TBIconditional recommendation, very low-quality evidence

Recommendations

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 recommendation, low-quality evidence). There is insufficient evidence to recommend either hypertonic saline or mannitol for improving neurological outcomes in patients with acute ischemic stroke.

Rationale:

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 mannitolconditional recommendation, low-quality evidence
We suggest against the use of prophylactic scheduled mannitol in acute ischemic stroke due to the potential for harmconditional recommendation, low-quality evidence

Recommendations for Hyperosmolar Therapy

We suggest using hypertonic sodium solutions over mannitol for the management of ICP or cerebral edema in patients with intracerebral hemorrhageconditional recommendation, very low-quality evidence

Rationale:

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 hemorrhageconditional recommendation, very low-quality evidence

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 complicationsstrong recommendation, moderate-quality evidence

Recommendations

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 meningitisstrong recommendation, moderate-quality evidence
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).
We recommend administering dexamethasone before or with the first dose of antibiotic in patients with bacterial meningitisstrong recommendation, moderate-quality evidence
We recommend use of corticosteroids to reduce mortality in patients with tuberculosis meningitis (strong recommendation, moderate quality of evidence). We cannot make a recommendation for one specific corticosteroid or dose in patients with TB meningitis due to the inconsistency of agents and doses evaluated in the literature.
We suggest that treatment with corticosteroids should be continued for two or more weeks in patients with tuberculosis meningitisconditional recommendation, low quality of evidence

Rationale:

There is insufficient evidence to determine whether hypertonic sodium solutions or mannitol is more effective to reduce ICP or cerebral edema in patients with community-acquired bacterial meningitis.

Recommendations

We suggest using either hypertonic sodium solutions or mannitol for the management of ICP or cerebral edema in patients with hepatic encephalopathyconditional recommendation, very low-quality evidence

Rationale:

There is insufficient evidence to determine whether either hyperosmolar therapy or ammonia-lowering therapy improves neurological outcomes in patients with hepatic encephalopathy.

Recommendations for Assessing the Risk of Renal Injury After Mannitol Administration

We suggest using osmolar gap over serum osmolarity thresholds during treatment with mannitol to monitor for the risk of AKIconditional recommendation, very low-quality evidence

Rationale:

There is insufficient evidence to recommend a cutoff value for osmolar gap when evaluating for the risk of acute kidney injury.
Renal function measures should be monitored closely in patients receiving mannitol due to the risk of AKI with hyperosmolar therapy (good practice statement).

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 recommendation, low-quality evidence). 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 injuryconditional recommendation, very low-quality evidence

Rationale:

Clinicians should routinely monitor both sodium and chloride serum concentrations to assess risk of AKI related to elevated concentrations (good practice statement).
Renal function should be monitored closely in patients receiving hypertonic sodium solutions due to the risk of AKI with hyperosmolar therapy (good practice statement).

Recommendations for the Optimal Administration Method of Hypertonic Sodium Solution

In patients with cerebral edema, how does continuous infusion of hypertonic sodium solutions compare to bolus infusion of hypertonic sodium solutions in improving neurological outcomes?
There is insufficient evidence to support use of a continuous infusion of HTS targeting a serum sodium goal for the purpose of improving neurological outcomes.
Due to insufficient evidence, we cannot recommend a specific dosing strategy for HTS to improve neurological outcomes in patients with cerebral edema.
Clinicians should avoid hyponatremia in patients with severe neurological injury due to the risk of exacerbating cerebral edema (good practice statement).

Recommendations for the Non-pharmacological Treatment of Cerebral Edema

We suggest that elevating the head of the bed to 30 degrees (but no greater than 45 degrees) be used as a beneficial adjunct to reduce intracranial pressureconditional recommendation, very low-quality evidence

Rationale:

We recommend that brief episodes of hyperventilation can be used for patients with acute elevations in intracranial pressurestrong recommendation, very low-quality evidence
We suggest that the use of CSF diversion be considered as a beneficial adjunct to reduce intracranial pressureconditional recommendation, very low-quality evidence
While non-pharmacological interventions may be effective for acute elevations in intracranial pressure, there is insufficient evidence that non-pharmacological interventions are effective for the treatment of any specific physiological changes that produce brain swelling related to cerebral edema.

Abstract

Background: Acute treatment of cerebral edema and elevated intracranial pressure is a common issue in patients with neurological injury. Practical recommendations regarding selection and monitoring of therapies for initial management of cerebral edema for optimal efficacy and safety are generally lacking. This guideline evaluates the role of hyperosmolar agents (mannitol, HTS), corticosteroids, and selected non-pharmacologic therapies in the acute treatment of cerebral edema. Clinicians must be able to select appropriate therapies for initial cerebral edema management based on available evidence while balancing efficacy and safety.

Methods: The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacy to create a panel in 2017. The group generated 16 clinical questions related to initial management of cerebral edema in various neurological insults using the PICO format. A research librarian executed a comprehensive literature search through July 2018. The panel screened the identified articles for inclusion related to each specific PICO question and abstracted necessary information for pertinent publications. The panel used GRADE methodology to categorize the quality of evidence as high, moderate, low, or very low based on their confidence that the findings of each publication approximate the true effect of the therapy.

Results: The panel generated recommendations regarding initial management of cerebral edema in neurocritical care patients with subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, intracerebral hemorrhage, bacterial meningitis, and hepatic encephalopathy.

Conclusion: The available evidence suggests hyperosmolar therapy may be helpful in reducing ICP elevations or cerebral edema in patients with SAH, TBI, AIS, ICH, and HE, although neurological outcomes do not appear to be affected. Corticosteroids appear to be helpful in reducing cerebral edema in patients with bacterial meningitis, but not ICH. Differences in therapeutic response and safety may exist between HTS and mannitol. The use of these agents in these critical clinical situations merits close monitoring for adverse effects. There is a dire need for high-quality research to better inform clinicians of the best options for individualized care of patients with cerebral edema.

Electronic supplementary material: The online version of this article (10.1007/s12028-020-00959-7) contains supplementary material, which is available to authorized users.

Contents of the original publication

The section headings of the original.

Introduction
Methods
Treatment of Cerebral Edema in Patients with Subarachnoid Hemorrhage
Treatment of Cerebral Edema in Patients with Traumatic Brain Injury
Treatment of Cerebral Edema in Patients with Acute Ischemic Stroke
Treatment of Cerebral Edema in Patients with Intracerebral Hemorrhage
Treatment of Cerebral Edema in Patients with Bacterial Meningitis
Treatment of Cerebral Edema in Patients with Hepatic Encephalopathy
Hyperosmolar Therapy Safety and Infusion Considerations
Recommendations for the Optimal Administration Method of Hypertonic Sodium Solution
Non-pharmacologic Treatment of Cerebral Edema and Elevated Intracranial Pressure
Summary
Source of Support
Compliance with Ethical Standards
Informed Consent

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