What are the initial management and treatment options for suspected brain oedema?

Initial Management and Treatment of Suspected Brain Edema

For patients with suspected brain edema, the initial management should focus on corticosteroid therapy (specifically dexamethasone) for symptomatic patients with neurological deficits, with standard doses ranging from 4-16 mg/day. 1

Assessment and General Measures

• Elevate the head of the bed 20-30° to optimize cerebral perfusion pressure, facilitate venous drainage, and help reduce intracranial pressure (ICP) 2
• Maintain proper head and body alignment to prevent increased intrathoracic pressure and allow venous drainage 2
• Ensure normothermia as hyperthermia can worsen cerebral edema 2
• Restrict free water to avoid hypo-osmolar fluid that may worsen edema 2
• Avoid excess glucose administration 2
• Minimize hypoxemia and hypercarbia 2

Pharmacological Management

Corticosteroids

• Dexamethasone is the most frequently administered drug for brain edema associated with brain tumors 1
• Standard doses range from 4-16 mg/day 1
• For cerebral edema associated with brain tumors, dexamethasone is generally administered initially in a dosage of 10 mg intravenously followed by 4 mg every six hours intramuscularly until symptoms subside 3
• Response is usually noted within 12-24 hours; dosage may be reduced after 2-4 days and gradually discontinued over 5-7 days 3
• Corticosteroids are NOT recommended for management of cerebral edema in ischemic stroke 1

Osmotic Therapy

• Mannitol (0.25 to 0.50 g/kg) administered over 20 minutes can be given every 6 hours 1
• Hypertonic saline is associated with rapid decrease in ICP in patients with clinical transtentorial herniation 2
• Serum and urine osmolality should be monitored if mannitol is used 1
• Osmotherapy may be trialed while a neurosurgical consultation is undertaken, or for patients with deteriorating condition due to raised intracranial pressure 1

Other Pharmacological Interventions

• Furosemide 40 mg can be used as adjunctive therapy but should not be used long-term 1
• Barbiturates can be considered for refractory intracranial hypertension 2
• Limited evidence on the anti-edema activity of boswellic acids, angiotensin-II inhibitors, hyperosmolar agents or corticorelin acetate does not support their regular use 1

Ventilation Management

• Hyperventilation may be used temporarily for life-threatening ICP increases, targeting mild hypocapnia (PCO₂ 30-35 mm Hg) 2
• Avoid prophylactic hyperventilation as it has not been shown to reduce incidence of cerebral edema 2

Surgical Management

• Selected patients (18–60 years) with significant middle cerebral artery infarction should be urgently referred to a neurosurgeon for consideration of hemicraniectomy within 48 hours of symptom onset 1
• Decompressive surgical evacuation of a space-occupying cerebellar infarction is effective in preventing and treating herniation and brain stem compression 1
• Placement of a ventricular drain is useful in patients with acute hydrocephalus secondary to ischemic stroke 1
• If hydrocephalus is present, fluid drainage through an intraventricular catheter can rapidly reduce ICP 1

Decision Algorithm for Brain Edema Management

1. Identify cause of brain edema:

   • Brain tumor: Use dexamethasone (4-16 mg/day) 1
   • Ischemic stroke: Avoid corticosteroids 1

2. For symptomatic patients with neurological deficits:

   • Initiate steroid treatment (for tumor-related edema) 1
   • Implement general measures (head elevation, normothermia) 2
   • Monitor for clinical improvement 1

3. If clinical improvement occurs:

   • Start tapering steroids 1
   • Eventually stop therapy 1

4. If no clinical improvement occurs:

   • Consider increasing steroid dose (for tumor-related edema) 1
   • Consider osmotherapy (mannitol or hypertonic saline) 1, 2
   • Consider neurosurgical consultation for potential surgical intervention 1

Important Considerations and Pitfalls

• Prophylactic use of steroids (e.g., perioperatively or during radiotherapy) is increasingly discouraged 1
• Long-term steroid use is associated with significant side-effects including increased risk for pneumocystis jiroveci pneumonia, diabetes, arterial hypertension, osteoporosis, myopathy, and psychiatric adverse effects 1
• Clinically-asymptomatic patients seldom require anti-edema treatment with steroids 1
• Patients receiving higher dexamethasone doses are more likely to suffer from side-effects 1
• In swollen hemispheric supratentorial infarcts, outcome can be satisfactory after decompressive surgery, but one should anticipate that one third of patients will be severely disabled and fully dependent on care 1