Key Guidelines and Evidence

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

The main pharmacologic interventions recommended include:

• Use symptom-based bolus dosing of hypertonic sodium solutions rather than sodium target-based dosing for managing elevated ICP or cerebral edema in patients with subarachnoid hemorrhage.
• Use hypertonic sodium solutions over mannitol for initial management of elevated ICP or cerebral edema in patients with traumatic brain injury.
• Use either hypertonic sodium solutions or mannitol for initial management of elevated ICP or cerebral edema in patients with acute ischemic stroke.
• Use hypertonic sodium solutions over mannitol for managing elevated ICP or cerebral edema in patients with intracerebral hemorrhage.
• Avoid corticosteroids in patients with intracerebral hemorrhage given increased risk of mortality and infections.
• Monitor osmolar gap over serum osmolarity thresholds during treatment with mannitol to assess risk of acute kidney injury.

Evidence

Study Design & Size:

• Kerwin et al. 2009 – Retrospective analysis, n=22 patients
• Burgess et al. 2016 – Meta-analysis, 7 trials, n=191 patients

Intervention and Outcomes:

• Kerwin et al. – HTS vs mannitol for mean ICP reduction in TBI patients
  • HTS more effective at reducing ICP than mannitol
• Burgess et al. – HTS vs mannitol for mean ICP reduction, ICP treatment failure, mortality, neurological outcomes
  • No difference in ICP reduction, mortality, or neurological outcomes
  • Decreased risk of ICP treatment failure with HTS vs mannitol

Key Takeaways:

• Evidence suggests HTS is at least as effective, if not more effective, than mannitol for reducing ICP in TBI patients
• HTS may lead to lower risk of ICP treatment failure compared to mannitol
• No clear differences demonstrated in mortality or neurological outcomes
• Overall, HTS appears to be a suitable alternative, if not preferred agent, over mannitol for ICP reduction in TBI