Medical management of cerebral edema

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✓Cerebral edema is frequently encountered in clinical practice in critically ill patients with acute brain injury from diverse origins and is a major cause of increased morbidity and death in this subset of patients. The consequences of cerebral edema can be lethal and include cerebral ischemia from compromised regional or global cerebral blood flow (CBF) and intracranial compartmental shifts due to intracranial pressure gradients that result in compression of vital brain structures. The overall goal of medical management of cerebral edema is to maintain regional and global CBF to meet the metabolic requirements of the brain and prevent secondary neuronal injury from cerebral ischemia. Medical management of cerebral edema involves using a systematic and algorithmic approach, from general measures (optimal head and neck positioning for facilitating intracranial venous outflow, avoidance of dehydration and systemic hypotension, and maintenance of normothermia) to specific therapeutic interventions (controlled hyperventilation, administration of corticosteroids and diuretics, osmotherapy, and pharmacological cerebral metabolic suppression). This article reviews and highlights the medical management of cerebral edema based on pathophysiological principles in acute brain injury.

Abbreviations used in this paper:BBB = blood-brain barrier; CBF = cerebral blood flow; CBV = cerebral blood volume; CPP = cerebral perfusion pressure; CSF = cerebrospinal fluid; CT = computed tomography; GCS = Glasgow Coma Scale; ICH = intracerebral hemorrhage; ICP = intracranial pressure; ICU = intensive care unit; PEEP = positive endexpiratory pressure; rCBF = regional CBF; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury; THAM = tris(hydroxymethyl)-aminomethane.

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Address reprint requests to: Anish Bhardwaj, M.D, Department of Neurology, Mackenzie Hall, Room 2204, 3181 SW Sam Jackson Park Road, L-226, Portland, Oregon 97239–3098. email:

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