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Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients

Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients, recommendations for patients with Subarachnoid Hemorrhage, Acute Ischemic Stroke and Intracerebral Hemorrhage, Brain Injury, Bacterial Meningitis and Hepatic Encephalopathy

A new guideline has been produced by experts in neurocritical care, nursing, and pharmacy recruited by The Neurocritical Care Society.

The focus of this guideline is the acute treatment of cerebral edema in neurocritical care patients.

The guideline considers:

  • Treatment of Cerebral Edema in Patients with Subarachnoid Hemorrhage, Acute Ischemic Stroke and Intracerebral Hemorrhage
  • Treatment of Cerebral Edema in Patients with Traumatic Brain Injury,
  • Treatment of Cerebral Edema in Patients with Bacterial Meningitis
  • Treatment of Cerebral Edema in Patients with Hepatic Encephalopathy
  • Hyperosmolar Therapy Safety and Infusion Considerations with recommendations for Assessing the Risk of Renal Injury After Mannitol Administration
  • Assessing the Risk of Toxicity (Acute Kidney Injury or Unwanted Acidosis) After Hypertonic Sodium Solution Administration
  • Optimal Administration Method of Hypertonic Sodium Solution
  • Non‑pharmacologic Treatment of Cerebral Edema and Elevated Intracranial Pressure

The evidence was assessed using the GRADE process and 28 recommendations and five good practice statements have been made.

The authors focus on recommendations mostly on osmotherapy , and in dexamethasone for bacterial meningitis.

No-pharmacological interventions were discussed for acute elevations in intracranial pressure, but it wasn´t addressed surgical decompression and therapeutic hypothermia, as they were adequately addressed by other guidelines and the overall quality of evidence was very low.


Key points:

  • Hyperosmolar therapy may help reduce ICP elevations or cerebral edema in patients with SAH, TBI, AIS, ICH, and HE, however neurological outcomes do not appear to be affected.
  • For patients with bacterial meningitis, corticosteroids appear to be helpful in reducing cerebral edema, although not in ICH.
  • There is a great need for high-quality research to better inform clinicians of the best options for individualized care of patients with cerebral edema.



Cook, A.M., Morgan Jones, G., Hawryluk, G.W.J. et al. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients. Neurocrit Care 32, 647–666 (2020). doi.org/10.1007/s12028-020-00959-7https://pubmed.ncbi.nlm.nih.gov/32227294/