Guideline sources The following summarized guidelines for the management of cerebral edema are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2023), the American Heart Association (AHA/ASA 2022; 2018), the Neurocritical Care Society (NCS 2020), the Brain Trauma Foundation (BTF 2017), the European Stroke Organisation (ESO 2014), and the Infectious Diseases Society of America (IDSA 2010). 1 2 3 4 6 7 8 10 10 10 11 12 Definition Cerebral edema is a disorder characterized by an increase in brain tissue water, including in individual cells and their surrounding tissues, with resultant intracranial hypertension. 10 Epidemiology Cerebral edema can be broadly classified as cytotoxic edema (due to ischemic stroke), vasogenic edema (due to neoplasm, hemorrhage, venous thrombosis, or arterio-venous shuts), or interstitial edema (due to hydrocephalus). 11 Disease course Cerebral edema presents with manifestations of intracranial hypertension, irreversible brain injury, cerebral herniation, and death. 10 https://web.pathway.md/diseases/recMzmcZm3uDFdjAw 1/5 6/29/23, 3:49 AM Cerebral edema Pathway Prognosis and risk of recurrence Cerebral edema associated with mass lesions is associated with an estimated in-hospital mortality of > 60%. In the context of ischemic stroke, the development of cerebral edema is associated with mortality of > 50%. 10 12 Guidelines 1. Inpatient care General principles: Monitor both sodium and chloride serum concentrations to assess risk of AKI related to hypernatremia and hyperchloremia. E Avoid hyponatremia in patients with severe neurological injury, due to the risk of exacerbating cerebral edema. D Elevation of the head of the bed: consider performing elevation of the head of the bed to 30 degrees (but no greater than 45 degrees) as a beneficial adjunct to reduce ICP. C Brief hyperventilation: consider performing brief episodes of hyperventilation for patients with acute elevations in ICP. B Monitoring of renal function: Monitor renal function closely in patients receiving mannitol, due to the risk of AKI with hyperosmolar therapy. E Monitor renal function closely in patients receiving hypertonic sodium solutions, due to the risk of AKI with hyperosmolar therapy. E Monitoring of serum sodium and chloride: Consider avoiding severe hypernatremia and hyperchloremia in patients receiving treatment with hypertonic sodium solutions, due to the association with AKI. D Consider targeting an upper serum sodium range of 155-160 mEq/L and a serum chloride range of 110-115 mEq/L in patients receiving hypertonic sodium solutions, in order to decrease the risk of AKI. C Monitoring of serum osmolar gap: consider using osmolar gap over serum osmolarity thresholds during treatment with mannitol to monitor for the risk of AKI. C 2. Therapeutic procedures CSF diversion: consider performing CSF diversion as a beneficial adjunct to reduce ICP. C 3. Specific circumstances https://web.pathway.md/diseases/recMzmcZm3uDFdjAw 2/5 6/29/23, 3:49 AM Cerebral edema Pathway Patients with traumatic brain injury: As per NCS 2020 guidelines, consider using hypertonic sodium solutions over mannitol for the initial management of elevated ICP or cerebral edema in patients with TBI. C Show 4 more As per BTF 2017 guidelines, treat ICP > 22 mmHg, as values above this level are associated with increased mortality. B Show 11 more Patients with acute ischemic stroke: As per NCS 2020 guidelines, consider using either hypertonic sodium solutions or mannitol for the initial management of ICP or cerebral edema in patients with acute ischemic stroke. C Show 2 more As per AHA 2018 guidelines, consider initiating osmotic therapy in patients with clinical deterioration from cerebral edema associated with cerebral infarction. C Show 2 more Patients with subarachnoid hemorrhage: consider 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 subarachnoid hemorrhage. C Patients with intracerebral hemorrhage: As per AHA 2022 guidelines, perform ventricular drainage to reduce mortality in patients with spontaneous intracerebral hemorrhage or intraventricular hemorrhage and hydrocephalus contributing to a reduced level of consciousness. B Show 4 more As per NCS 2020 guidelines, consider administering hypertonic sodium solutions over mannitol for the management of ICP or cerebral edema in patients with intracerebral hemorrhage. C Show 2 more As per ESO 2014 guidelines, do not use dexamethasone in patients with acute intracerebral hemorrhage outside of a clinical trial. D Patients with hepatic encephalopathy: consider using either hypertonic sodium solutions or mannitol for the management of ICP or cerebral edema in patients with hepatic encephalopathy. C Patients with bacterial meningitis: administer dexamethasone (10 mg intravenous every 6 h, for 4 days) to reduce neurological sequelae (primarily hearing loss) in patients with community- acquired bacterial meningitis. B Show 2 more Patients with tuberculous meningitis: As per NCS 2020 guidelines: Administer corticosteroids to reduce mortality in patients with tuberculosis meningitis. B Consider continuing treatment with corticosteroids for 2 weeks in patients with tuberculosis meningitis. C https://web.pathway.md/diseases/recMzmcZm3uDFdjAw 3/5 6/29/23, 3:49 AM Cerebral edema Pathway Patients with cryptococcal meningitis: As per CDC 2023 guidelines, do not use mannitol or corticosteroids for elevated ICP because of the ineffectiveness. D Do not use acetazolamide for elevated ICP because it is ineffective and may exacerbate hyperchloremic acidosis from amphotericin B. D Show 6 more As per IDSA 2010 guidelines: Administer corticosteroids as adjunctive therapy for mass effect and surrounding edema. B Consider performing open or stereotactic-guided debulkment and/or removal of large (3 cm) and accessible lesions with mass effect. C Clinical findings Symptoms Past medical history Blurry vision Brain tumor Difficulty walking Encephalitis Dizziness Meningitis Double vision Stroke Headache Traumatic injury Infection Ocular exam Memory impairment Nausea Central vision loss Neck pain Vomiting Neurological exam Neck stiffness Studies 2016 RESCUEicp In patients with TBI and refractory elevated ICP (> 25 mmHg), surgical was superior to medical with respect to death at 6 months. Hutchinson PJ et al. N Engl J Med. 2016 Sep 22. References 1. Aaron M Cook, G Morgan Jones, Gregory W J Hawryluk et al. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients. Neurocrit Care. 2020 Jun;32 3 647 666. Open https://web.pathway.md/diseases/recMzmcZm3uDFdjAw 4/5 6/29/23, 3:49 AM Cerebral edema Pathway 2. Carney N, Totten AM, O'Reilly C et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80 1 6 15. Open 3. Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Department of Health and Human Services. 2023. Open 4. Steven M Greenberg, Wendy C Ziai, Charlotte Cordonnier et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 May 17;101161STR0000000000000407. Open 5. Payam Nahid, Susan E Dorman, Narges Alipanah et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis. 2016 Oct 1;63 7):e147-e195. Open 6. Thorsten Steiner, Rustam Al-Shahi Salman, Ronnie Beer et al. European Stroke Organisation ESO guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014 Oct;9 7 840 55. Open 7. Powers WJ, Rabinstein AA, Ackerson T et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49 3):e46-e110. Open 8. Perfect JR, Dismukes WE, Dromer F et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2010 Feb 1;50 3 291 322. Open 9. No authors listed. Guidelines for treatment of drug-susceptible tuberculosis and patient care. Geneva: World Health Organization; 2017. Open 10. Ruchira M Jha, Patrick M Kochanek, J Marc Simard. Pathophysiology and treatment of cerebral edema in traumatic brain injury. Neuropharmacology. 2019 Feb;145 Pt B 230 246.2019 Feb;145 Pt B 230 246. Open 11. Dalia Adukauskiene, Asta Bivainyte, Edita Radavici te. Cerebral edema and its treatment. Medicina Kaunas). 2007;43 2 170 6. Open 12. S E Kasner, A M Demchuk, J Berrouschot et al. Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke. 2001 Sep;32 9 2117 23.2001 Sep;32 9 2117 23. Open 13. Ruchira M. Jha, Patrick M. Kochanek, and J. Marc Simard. Pathophysiology and Treatment of Cerebral Edema in Traumatic Brain Injury. Neuropharmacology. 2019 Feb; 145 Pt B 230 246. Open 14. Dalia Adukauskiene, Asta Bivainyte, Edita Radaviciute. Cerebral edema and its treatment]. Medicina Kaunas). 2007;43 2 170 6.2007;43 2 170 6. Open https://web.pathway.md/diseases/recMzmcZm3uDFdjAw 5/5