Cerebral Edema and Elevated Intracranial Pressure

Matthew A. Koenig, MD, FNCS p. 1588-1602 December 2018, Vol.24, No.6 doi: 10.1212/CON.0000000000000665
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PURPOSE OF REVIEW: This article reviews the management of cerebral edema, elevated intracranial pressure (ICP), and cerebral herniation syndromes in neurocritical care.

RECENT FINDINGS: While corticosteroids may be effective in reducing vasogenic edema around brain tumors, they are contraindicated in traumatic cerebral edema. Mannitol and hypertonic saline use should be tailored to patient characteristics including intravascular volume status. In patients with traumatic brain injury who are comatose, elevated ICP should be managed with an algorithmic, multitiered treatment protocol to maintain an ICP of 22 mm Hg or less. Third-line ICP treatments include anesthetic agents, induced hypothermia, and decompressive craniectomy. Recent clinical trials have demonstrated that induced hypothermia and decompressive craniectomy are ineffective as early neuroprotective strategies and should be reserved for third-line management of refractory ICP elevation in severe traumatic brain injury. Monitoring for cerebral herniation should include bedside pupillometry in supratentorial space-occupying lesions and recognition of upward herniation in patients with posterior fossa lesions.

SUMMARY: Although elevated ICP, cerebral edema, and cerebral herniation are interrelated, treatments should be based on the distinct pathophysiologic process. Focal lesions resulting in brain compression are primarily managed with surgical decompression, whereas global or multifocal brain injury requires a treatment protocol that includes medical and surgical interventions.

Address correspondence to Dr Matthew A. Koenig, The Queen’s Health Systems, 1301 Punchbowl St, Neuroscience Institute QET5, Honolulu, HI 96816, mkoenig@queens.org.

RELATIONSHIP DISCLOSURE: Dr Koenig has received research/grant support as principal investigator of a study for the Hawaii Department of Health Neurotrauma Special Fund and receives publishing royalties from Rutgers University Press.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Koenig reports no disclosure.

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© 2018 American Academy of Neurology