What is the treatment for acute brain herniation (also known as transtentorial herniation)?

From the Guidelines

Treatment for acute brain herniation should prioritize the use of osmotic agents, specifically mannitol 20% or hypertonic saline solution, at a dose of 250 mOsm, in infusion of 15–20 minutes to rapidly reduce intracranial pressure and prevent further brain damage, as recommended by the most recent and highest quality study 1. The primary goal of treatment is to stabilize the patient and reduce intracranial pressure through a combination of medical and surgical approaches. Key considerations include:

• Elevating the head of the bed to 30 degrees to reduce intracranial pressure
• Ensuring adequate oxygenation and maintaining systolic blood pressure between 140-160 mmHg to preserve cerebral perfusion
• Using hyperventilation to a PaCO2 of 30-35 mmHg as a temporary measure to cause cerebral vasoconstriction, but limiting its use to 2-3 hours to avoid ischemia, as suggested by 1 and 1
• Administering osmotic agents, with mannitol being the first-line treatment, followed by hypertonic saline if needed, as supported by 1
• Considering sedation and neuromuscular blockade to reduce metabolic demand and prevent further increases in intracranial pressure
• Evaluating the need for emergent surgical decompression, including hemicraniectomy or targeted evacuation of mass lesions, for definitive treatment, as implied by the need for rapid reduction of intracranial pressure in cases of brain herniation. It is essential to note that temperature control is also a critical component of managing intracranial pressure, with controlled normothermia being recommended as an addition to tier 1 and 2 treatments, as suggested by 1. However, the primary focus should remain on rapidly reducing intracranial pressure using osmotic agents and other medical and surgical interventions.

From the FDA Drug Label

Mannitol, when administered intravenously, exerts its osmotic diuretic effect as a solute of relatively small molecular size largely confined to the extracellular space. ... By increasing the osmotic pressure of plasma and the extracellular space, intravenously administered mannitol will induce the movement of intracellular water to the extracellular and vascular spaces. This action underlies the role of mannitol in reducing intracranial pressure, intracranial edema, and intraocular pressure.

The treatment for acute brain herniation (also known as transtentorial herniation) may include mannitol (IV) to help reduce intracranial pressure.

• Key benefits: reducing intracranial edema and intraocular pressure
• Mechanism of action: increasing osmotic pressure to move intracellular water to extracellular and vascular spaces 2

From the Research

Treatment for Acute Brain Herniation

The treatment for acute brain herniation, also known as transtentorial herniation, involves several medical and surgical approaches to manage intracranial hypertension and prevent further brain damage. Some of the key treatments include:

• Hyperventilation to reduce intracranial pressure, which may be life-saving in the setting of acute brainstem herniation 3
• Normoventilation in the prehospital setting to avoid abnormal Pco(2) levels, which are correlated with increased in-hospital mortality 3
• Decompressive craniectomy to relieve pressure on the brain and improve outcomes in patients with severe traumatic brain injury 4, 5
• Barbiturate coma to control intracranial pressure and improve outcomes in patients with severe traumatic brain injury 4, 5
• External ventricular drainage to remove cerebrospinal fluid and relieve pressure on the brain 4
• Hyperosmolar therapy to reduce intracranial pressure and improve outcomes in patients with severe traumatic brain injury 5

Medical Management

Medical management of acute brain herniation involves several key strategies, including:

• Maintaining normocarbia (normal Pco(2) levels) to avoid increasing intracranial pressure 3
• Avoiding hypotension and hypercapnia to prevent further brain damage 5
• Using hyperosmolar therapy to reduce intracranial pressure and improve outcomes 5
• Monitoring serum sodium and osmolality levels to estimate mortality risk and guide treatment decisions 5

Surgical Management

Surgical management of acute brain herniation involves several key procedures, including:

• Decompressive craniectomy to relieve pressure on the brain and improve outcomes in patients with severe traumatic brain injury 4, 5
• External ventricular drainage to remove cerebrospinal fluid and relieve pressure on the brain 4
• Craniotomy to remove intracranial mass lesions and relieve pressure on the brain 5