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Cerebral edema

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.
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Pathophysiology
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).
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Disease course
Cerebral edema presents with manifestations of intracranial hypertension, irreversible brain injury, cerebral herniation, and death.
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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%.
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Key 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 World Health Organization (WHO 2017), the European Stroke Organisation (ESO 2014), and the Infectious Diseases Society of America (IDSA 2010).
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Guidelines

1.Inpatient care

General principles
Monitor both sodium and chloride serum concentrations to assess risk of AKI related to hypernatremia and hyperchloremia.
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Avoid hyponatremia in patients with severe neurological injury, due to the risk of exacerbating cerebral edema.
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  • Elevation of the head of the bed

  • Brief hyperventilation

  • Monitoring of renal function

  • Monitoring of serum sodium and chloride

  • Monitoring of serum osmolar gap

2.Therapeutic procedures

Cerebrospinal fluid diversion: consider performing CSF diversion as a beneficial adjunct to reduce ICP.
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3.Specific circumstances

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 traumatic brain injury.
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  • Patients with AIS

  • Patients with subarachnoid hemorrhage

  • Patients with intracerebral hemorrhage

  • Patients with hepatic encephalopathy

  • Patients with bacterial meningitis

  • Patients with tuberculous meningitis

  • Patients with cryptococcal meningitis