Management Of Cerebral Edema Research Articles

Diagnosis and management of pediatric acute liver failure: consensus recommendations of the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ISPGHAN).

Timely diagnosis and management of pediatric acute liver failure (PALF) is of paramount importance to improve survival. The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international experts to identify and review important management and research questions. These covered the definition, age appropriate stepwise workup for the etiology, non-invasive diagnosis and management of cerebral edema, prognostic scores, criteria for listing for liver transplantation (LT) and bridging therapies in PALF. Statements and recommendations based on evidences assessed using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were developed, deliberated and critically reappraised by circulation. The final consensus recommendations along with relevant published background information are presented here. We expect that these recommendations would be followed by the pediatric and adult medical fraternity to improve the outcomes of PALF patients.

NURS-11. NEURO-ONCOLOGIC EMERGENCY MANAGEMENT

Abstract BACKGROUND Due to disease location, neuro-oncology patients experience emergencies that are infrequently encountered in general oncology and require unique interventions. Paramount among these emergencies is vasogenic cerebral edema (CE). Urgent and accurate interventions are needed to decrease associated morbidity and mortality. In an educational institution, access to knowledge of next steps is crucial. This prompted further inquiry of best practice into recognition of increasing intracranial pressure (ICP) and management of cerebral edema using a literature review and reflection on institutional experience. METHODS A literature review was conducted using pubmed to identify articles through January 2014. The Key words used in the search included “neuro-ongologic emergencies” “brain herniation management” “cerebral edema. RESULTS The searched yielded 3237 results. Of these, 3236 were excluded. Ten full text articles were relevant and included in the review. In combination with the literature and institutional experience of neuro-oncological emergencies, interventions and outcomes were evaluated to provide recommendations for treatment in the event of an emergency. CONCLUSION CE is not an uncommon finding with malignant brain tumors given disrupted blood brain barrier. This subsequently increases ICP and left unmanaged, can lead to brain herniation. Signs and symptoms can vary depending on tumor location and extent of edema. Most common exam findings to be aware of include headache, nausea, vomiting, altered pupil exam, abnormal eye movements, and altered consciousness. Ultimately surgical intervention may be the definitive treatment, non-surgical management is important. Literature review supported the use of both high dose dexamethasone and hyperosmolar solutions are temporizing measures to decrease CE. Additional measures such as positioning, treatment of pain or fever, are also recommended. Prompt recognition and intervention of CE are crucial to improved patient outcomes. An educational poster with recommendations for best practice when encountering neuro-oncological emergencies will be created. Dissemination of findings will be done at local, national and international levels.

Comparison of 3% hypertonic saline vs mannitol in the management of cerebral edema in patients with acute ischemic stroke: A prospective comparative study

Comparison of 3% hypertonic saline vs mannitol in the management of cerebral edema in patients with acute ischemic stroke: A prospective comparative study

The role of early cerebral edema and hematoma assessment in aneurysmal subarachnoid hemorrhage (a-SAH) in predicting structural brain abnormalities in cognitive impairments-- case controlled study.

Early assessment and management of cerebral edema and hematoma following aneurysmal subarachnoid hemorrhage (a-SAH) can significantly impact clinical cognitive outcomes. However, current clinical practices lack predictive models to identify early structural brain abnormalities affecting cognition. To address this gap, we propose the development of a predictive model termed the a-SAH Early Brain Edema/Hematoma Compression Neural (Structural Brain) Networks Score System (SEBE-HCNNSS). In this study, 202 consecutive patients with spontaneous a-SAH underwent initial computed tomography (CT) or magnetic resonance imaging (MRI) scans within 24 hours of ictus with follow-up 2 months after discharge. Using logistic regression analysis (univariate and multivariate), we evaluated the association of clinically relevant factors and various traditional scale ratings with cognitive impairment (CI). Risk factors with the highest area under the curve (AUC) values were included in the multivariate analysis and least absolute shrinkage and selection operator (LASSO) analysis or Cox regression analysis. A total of 177 patients were enrolled in the study, and 43 patients were classified with a high SEBE-HCNNSS grade (3 to 5). After a mean follow-up of 2 months, 121 individuals (68.36%) with a-SAH and 3 control subjects developed incident CI. The CT inter-observer reliability of the SEBE-HCNNSS scale was high, with a Kappa value of 1. Furthermore, ROC analysis identified the SEBE-HCNNSS scale (OR 3.322, 95% CI 2.312-7.237, P=0.00025) as an independent predictor of edema, CI, and unfavorable prognosis. These results were also replicated in a validation cohort. Overall, the SEBE-HCNNSS scale represents a simple assessment tool with promising predictive value for CI and clinical outcomes post-a-SAH. Our findings indicate its practical utility as a prognostic instrument for risk evaluation after a-SAH, potentially facilitating early intervention and treatment.

Safety and efficacy of glibenclamide on cerebral oedema following aneurysmal subarachnoid haemorrhage: a randomised, double-blind, placebo-controlled clinical trial

BackgroundGlibenclamide has garnered attention due to its multifaceted neuroprotective effects in cases of acute central nervous system injury. We initiated a trial to explore the effectiveness and safety of a...

Efficacy of Mannitol in the Management of Cerebral Oedema in Hypoxic Ischemic Encephalopathy Stage-II following Perinatal Asphyxia in a Tertiary Level Hospital

Background: The use of mannitol in reducing cerebral edema in case of perinatal asphyxia in Hypoxic Ischemic Encephalopathy Stage-II is considerably contributing.
 Objective: To find out the efficacy of mannitol in reducing cerebral edema in Hypoxic Ischemic Encephalopathy Stage-II following perinatal asphyxia.
 Methods: It was a prospective observational study done in the Paediatric department of Shahid Suhrawardy Medical College Hospital, Dhaka from September 2016 to February 2017. According to inclusion criteria total 120 neonates were included in this study by purposive sampling. Among them, 60 neonates were selected as case (treated with mannitol) and 60 were taken as control (treated without mannitol). Data were collected in a structured questionnaire.
 Results: During the study period, a total of 120 patients were studied. In the study group (Group -A), 78.33% were delivered by LUCS whereas in Group-B, the figure was 66.6%. The mean birth weight of neonates of these two groups were 1.9 + 0.76 kg and 1.73 + 0.89 kg respectively. PROM, APH, malpresentation, and multiple gestation were statistically significant risk factors in both groups (P=<0.05). About 79.67% neonates of group-A (with mannitol) and 70% of group-B (without mannitol) had radiological improvement following treatment revealing no statistically significant difference (P= >0.05).
 Conclusion: From the result of the present study, it can be concluded that there is no significant difference in the management of cerebral edema following perinatal asphyxia with HIE stage-II between the groups treated with mannitol and without mannitol.
 J Shaheed Suhrawardy Med Coll 2022; 14(1): 12-15

IMPAIRED CEREBRAL AUTOREGULATION IN PATIENTS WITH ADVANCED LIVER FAILURE: AN UNDER-RECOGNIZED PHENOMENON

IMPAIRED CEREBRAL AUTOREGULATION IN PATIENTS WITH ADVANCED LIVER FAILURE: AN UNDER-RECOGNIZED PHENOMENON

Rhino-orbital-cerebral mucormycosis in times of COVID-19: A neurosurgical experience.

Background: The gravity of “second wave” of COVID-19 has effaced many new challenges in India; mucormycosis being a recent one. Diabetes mellitus (DM) is a known significant risk factor for mucormycosis. Here, we present our experience with rhino-orbital-cerebral mucormycosis (ROCM) during the “second wave of COVID-19” at a tertiary health care centre in North India.Methods: This case series includes four cases of ROCM that were managed by our neurosurgical team in view ofcerebral involvement.Results: All the cases with an exception of one (Case 1), had a history of treatment for COVID-19 pneumonia. Case 2, 3 had undergone functional endoscopic sinus surgery (FESS) and orbital decompression before the onset of cerebral involvement; Case 4 underwent FESS and cranial surgery in the same sitting. All the patients had a history of DM and all the cases treated for COVID-19 pneumonia had a history of treatment with corticosteroids. Two patients underwent surgery with the exception of one patient, who did not provide consent for the same. One patient expired before surgical excision could be attempted.Conclusion: Regular and intensive follow-up is the key in swift detection and management of ROCM in post-COVID patients. While surgical excision is advisable in the fungal lesion, it must be borne in mind that radical excision of cerebral lesions is associated with morbidity, delayed recovery, and prolonged ICU stay. Culture and sensitivity-based antibiotics should be used judiciously as fever is a common postoperative complication. Blood sugar monitoring and control of DM are paramount in this condition. Steroids should be avoided in the management of cerebral edema with judicious use of hypertonic saline or mannitol.

Management of Cerebral Edema, Brain Compression, and Intracranial Pressure.

This article reviews the pathophysiology and management of cerebral edema, brain compression, and elevated intracranial pressure (ICP). It also provides a brief introduction to the concept of the glymphatic system and select cellular contributors to cerebral edema. Cerebral edema and brain compression should be treated in a tiered approach after the patient demonstrates a symptomatic indication to start treatment. All patients with acute brain injury should be treated with standard measures to optimize intracranial compliance and minimize risk of ICP elevation. When ICP monitors are used, therapies should target maintaining ICP at 22 mm Hg or less. Evidence exists that serial clinical examination and neuroimaging may be a reasonable alternative to ICP monitoring; however, clinical trials in progress may demonstrate advantages to advanced monitoring techniques. Early decompressive craniectomy and hypothermia are not neuroprotective in traumatic brain injury and should be reserved for situations refractory to initial medical interventions. Medical therapies that acutely lower plasma osmolality may lead to neurologic deterioration from osmotic cerebral edema, and patients with acute brain injury and renal or liver failure are at elevated risk. A tiered approach to the management of cerebral edema and brain compression can reduce secondary brain injury when implemented according to core physiologic principles. However, our knowledge of the pathophysiology of acute brain injury is incomplete, and the conceptual framework underlying decades of clinical management may need to be revised in response to currently evolving discoveries regarding the pathophysiology of acute brain injury.

Management of Cerebral Edema in Acute Liver Failure.

Advances in medical care of the acute liver failure patient have led to a significant reduction in mortality related to the condition. Nevertheless, cerebral edema and ensuing brain herniation remains one of the top causes of demise in acute liver failure. Controversy remains regarding the utility of invasive intracranial pressure monitoring as well as usage of novel treatment modalities including therapeutic hypothermia. This review provides a brief summary into the pathophysiology and risk factors for developing cerebral edema in the context of acute liver failure; this review particularly provides a practical focus on general management of the patient with established cerebral edema as well as specific intracranial pressure-lowering strategies.

Study of drugs used in cerebral edema in patients with stroke at a tertiary care center

Background: Various medical and surgical measures have been evolved to treat the raised intracranial pressure (ICP). Medical management mainly involves osmotic agents (glycerol and mannitol), diuretics, and corticosteroids to reduce raised ICP. It is not presently clear whether the routine use of mannitol, glycerol, and corticosteroids results in increased survival and decreased dependency in stroke patients. Aims and Objectives: To study the practice pattern of drugs used in the management of cerebral edema in stroke. Materials and Methods: The retrospective medical records of stroke patients receiving treatment from July 2013 to February 2013 at Fr. Muller Medical College Hospital were reviewed. Data regarding anti-cerebral edema drugs prescribed, co-prescribed drugs was collected from the records. Demographic data, age, gender,hospital medical records number, data regarding anti cerebral edema drugs, co prescribed medicines, clinical outcome in terms of improved/dead/discharged against medical advice, etc., were recorded. Patients above 18 years of age of either sex diagnosed with CVA and on treatment were included in the study. Data were analyzed using suitable statistical methods. Results: According to our study results, drugs were generally not used for the management of cerebral edema. Mannitol was the most common drug used in the management of cerebral edema in stroke (34.93%), followed by furosemide (26.5%), corticosteroids (8.46%), glycerol in 7.23%, and others including torsemide or aldactone (10.84%). Various combinations of these drugs were used. Conclusion: Various combinations of anti-edema drugs were used, no standard protocol was followed, and treatment was highly individualized. Predicting clinical outcome needs development of uniform protocols and further studies to standardize the practice of using drugs to manage cerebral edema routinely in stroke.

Progress in Drug Treatment of Cerebral Edema

Cerebral edema causes intracranial hypertension (ICH) which leads to severe outcome of patients in the clinical setting. Effective anti-edema therapy may significantly decrease the mortality in a variety of neurological conditions. At present drug treatment is a cornerstone in the management of cerebral edema. Osmotherapy has been the mainstay of pharmacologic therapy. Mannitol and hypertonic saline (HS) are the most commonly used osmotic agents. The relative safety and efficacy of HS and mannitol in the treatment of cerebral edema and reduction of enhanced ICP have been demonstrated in the past decades. Apart from its osmotic force, HS exerts anti-edema effects partly through inhibition of Na(+)-K(+)-2Cl(-) Cotransporter-1 (NKCC1) and aquaporin 4 (AQP4) expression in astrocytes. Melatonin may also reduce brain edema and exert neuroprotective effect on several central nervous system diseases through inhibition of inflammatory response. The inhibitors of Na/H exchanger, NKCC and AQP4 may attenuate brain edema formation through inhibition of excessive transportation of ion and water from blood into the cerebral tissue. In this review we survey some of the most recent findings in the drug treatment of brain edema focusing on the use of osmotherapy, melatonin and inhibitors of ion cotransporters and water channels. A better understanding of the molecular mechanism of these agents would help to improve in the clinical management of patients with brain edema.

PS014 - Hypertonic Saline versus Mannitol in the Management of Cerebral Edema in Acute Liver Failure: A Randomized Open Label Control Trial

PS014 - Hypertonic Saline versus Mannitol in the Management of Cerebral Edema in Acute Liver Failure: A Randomized Open Label Control Trial

Dexamethasone administration during definitive radiation and temozolomide renders a poor prognosis in a retrospective analysis of newly diagnosed glioblastoma patients.

BackgroundDexamethasone (DXM) is commonly used in the management of cerebral edema in patients diagnosed with glioblastoma multiforme (GBM). Bevacizumab (BEV) is FDA-approved for the progression or recurrence of GBM but has not been shown to improve survival when given for newly diagnosed patients concurrently with radiation (RT) and temozolomide (TMZ). Both DXM and BEV reduce cerebral edema, however, DXM has been shown to induce cytokine cascades which could interfere with cytotoxic therapy. We investigated whether DXM would reduce survival of GBM patients in the setting of concurrent TMZ and BEV administration.MethodsWe reviewed the treatment of all 73 patients with GBM who received definitive therapy at our institution from 2005 to 2013 with RT (60 Gy) delivered with concurrent daily TMZ (75 mg/m2). Of these, 34 patients also were treated with concurrent BEV (10 mg/kg every two weeks). Patients received adjuvant therapy (TMZ or TMZ/Bev) until either progression, discontinuation due to toxicity, or 12 months after radiation completion. All patients who had GBM progression with TMZ were offered BEV for salvage therapy, with 19 (56 %) receiving BEV.ResultsWith a median follow-up of 15.6 months, 67 (91.8 %) patients were deceased. The OS for the entire cohort was 15.9 months, while the PFS was 7.7 months. The extent of resection was a prognostic indicator for OS (p = .0044). The median survival following gross tumor resection (GTR) was 22.5 months, subtotal resection (STR) was 14.9 months, and biopsy was 12.1 months. The addition of BEV to TMZ with RT was borderline significantly associated with increased PFS (9.4 vs. 5.1 months, p = 0.0574) although was not significantly associated with OS (18.1 vs. 15.3 months respectively, p = 0.3064). In patients receiving TMZ, DXM use concurrent with RT was a poor prognostic indicator of both OS (12.7 vs. 22.6 months, p = 0.003) and PFS (3.6 vs. 8.4 months, p <0.0001). DXM did not reduce OS in patients who received TMZ and BEV concurrently with RT (22.9 vs 22.8 months, p = 0.4818). On multivariable analysis, DXM use predicted an unfavorable OS hazard ratio (HR) = 1.72, p = 0.045).ConclusionsOur results with TMZ, BEV, and RT are similar to previous studies in terms of PFS and OS. DXM use during RT with concurrent TMZ correlated with reduced OS and PFS unless BEV was administered.

Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments.

Diabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences. Pediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema. Responses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5-20 mL/kg) and length of time boluses should be administered (20-120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration. This is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.

Complications in acute liver failure: managing hepatic encephalopathy and cerebral oedema

Acute liver failure (ALF) is a term that first became established in the 1960s to describe a rare clinical syndrome that is characterised by severe hepatocyte injury, jaundice, and hepatic encephalopathy, usually in the absence of pre-existing chronic liver disease. ALF has a variety of aetiologies, and is associated with a high mortality and morbidity. While it is a disease of multiorgan failure, all patients with ALF will have some degree of hepatic encephalopathy, which when advanced, is associated with a high incidence of cerebral oedema and intracranial hypertension. When these symptoms are combined with other failing bodily systems, this group of patients is extremely challenging to manage. This article presents an overview of hepatic encephalopathy and the management of cerebral oedema in this group of patients, examining both current medical and nursing strategies.

Higher diastolic blood pressure at admission and antiedema therapy is associated with acute kidney injury in acute ischemic stroke patients

Antiedema therapy with mannitol and furosemide is widely used for prevention and management of cerebral edema, elevated intracranial pressure, and cerebral hernia. There are some reports about mannitol and furosemide as risk factors of acute kidney injury (AKI). We investigated the risk factors for AKI including antiedema therapy in acute ischemic stroke patients. The subjects were 129 patients with acute ischemic stroke including 56 females and 73 males with a mean age 68.16±12.29 years. Patients were divided into two groups: patients with AKI and without AKI according to Acute Kidney Injury Network criteria. All patients had undergone cranial, carotid, and vertebral artery evaluation with magnetic resonance imaging. The number of patients with AKI was 14 (10.9%). Subjects experiencing atrial fibrillation (P=0.043) and higher diastolic blood pressure (DBP) (P=0.032) treated with mannitol (P=0.019) and furosemide (P=0.019) disclosed significant association with AKI. Regression analysis revealed that higher DBP (P=0.029) and management with mannitol (P=0.044) were the risk factors for AKI. Higher DBP at admission is the most important risk factor for AKI. However antiedema therapy should be used carefully in patients with acute ischemic stroke. Serum creatinine levels or estimated glomerular filtration rate should be watched frequently to prevent AKI.

Management of Acute Ischemic Stroke

Acute stroke affects about 800,000 patients annually in the US and is the leading cause of disability. It is a complex condition with multiple causes and requires comprehensive but rapid evaluation by stroke specialists working in institutions with well-organized stroke systems of care. Acute stroke treatment is focused on early revascularization with intravenous tPA for those with strokes under 3 hours duration or intra-arterial therapy for most others and those who cannot receive tPA. The latter is evolving rapidly with the advent of stent-retriever embolectomy devices that are poised to revolutionize stroke treatment. Recanalization is associated with neurological recovery in 33-50 % of patients. This also means that many patients may have devastating and life-threatening brain injury, which highlights the need for comprehensive care for the prevention and treatment of medical complications, management of cerebral edema and intracerebral hemorrhage.

Hyperosmolar Therapy for the Intracranial Hypertension in Neurosurgical Practice: Mannitol Versus Hypertonic Saline

Management of cerebral edema and elevated intracranial pressure (ICP) is a critical determinant of patient outcomes. Osmotherapy is the most important options in the medical treatments including controlled ventilation, osmotherapy, maintenance of brain and body homeostasis and sedation. Mannitol and hypertonic saline (HTS) are frequently used among osmotic agents related to brain edema and high ICP. Although mannitol is recommended in guidelines, hypertonic saline seems advantageous over mannitol in many situations, such as providing sustained hemodynamic stability and immunologic effects and less rebound phenomenon. Thus, HTS is emerging as a secure alternative to mannitol in the treatment of intracranial hypertension.

Abstract 2672: Osmotic Therapy in the Management of Cerebral Edema after Stroke across the United States.

Introduction Osmotically active substances like mannitol and hypertonic saline are widely accepted options in management of cerebral edema after ischemic stroke. However, use of these agents can be very heterogeneous in practice given the lack of randomized clinical trials to confirm and compare their effectiveness. We queried the PREMIER database to investigate the differences in the use of osmotic therapy in ischemic stroke patients across the United States. Methods First ever ischemic stroke-related hospitalizations (ICD-9 codes 433.x1, 434.x1 and 436) of patients aged 18+ years were reviewed for fiscal years of 2007-2010 from the Premier Perspective™ Database. Use of osmotic therapy and time of its administration were determined through pharmacy billing records for mannitol and hypertonic saline while presence of documented cerebral edema was identified using ICD-9 diagnosis code 348.5.Differences in osmotic treatment were tested by gender and race of the patient as well as hospital characteristics. Results We identified 244,482 patients with first ever ischemic stroke. Of these, 12,301 (5%) were treated with osmotic therapy, the majority of which occurred within 7 days of hospitalization. Of those receiving osmotic therapy, 64% received mannitol, 44% received hypertonic saline and 7% received both treatments. The ICD -9 code for cerebral edema was associated to 11% of these cases. Essentially no differences in race (63% whites) and sex distribution (49% females) were found. The majority of osmotic therapy use occurred in urban areas (93%). There was no difference in use between teaching vs non-teaching institutions (51% vs 49%). Conclusions Despite the lack of evidence to support its effectiveness, we found that osmotic therapy was given to 5% of stroke patients during fiscal years 2007-2010, primarily in urban centers. Only a minority of treated cases were associated with the ICD-9 code for cerebral edema, which is the principal indication for this treatment, likely reflecting a diffuse underutilization of this diagnostic code in practice. Mannitol was more frequently used than hypertonic saline in both teaching and non-teaching hospitals. Randomized control trials are warranted to demonstrate the efficacy of osmotic therapy using mannitol or hypertonic saline in ischemic stroke.