Oedema, Cerebral

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Clinical Description

Swelling of brain parenchymal tissue, due to vasogenic, cytotoxic and osmotic causes. Only the vasogenic causes, such as brain tumours and inflammation, respond to corticosteroids.

Treatment

  • Consider mannitol for brain oedema in traumatic brain injury causing raised intracranial pressure, pending neurosurgical intervention.

BRAIN OEDEMA DUE TO TUMOURS AND INFLAMMATIONGeneral Measures

  • Supportive management.
  • Rehabilitation intervention

Treatment 

  • Treat the underlying cause. This is especially important with brain oedema associated with systemic conditions, such as electrolyte disturbances and organ failure.
  • Patients with primary brain tumours or brain metastases should be considered for specific treatment of the tumor, which includes surgery and/or radiotherapy.
  • Give Dexamethasone, IV, 4 mg 6 hourly initially.

OR

  •  Give Betamethasone, oral/IV, 4 mg 6 hourly. Discontinue if no response has occurred after 48 hours. Taper dose according to response and duration of therapy.

BRAIN OEDEMA DUE TO TRAUMATIC INJURY

General Measures

  • Refer patient for neurosurgical opinion, if indicated.
  • Supportive management.
  • Rehabilitation intervention.

Note: DVT prophylaxis with heparin may be contraindicated owing to risk of increased bleeding.

  • The following measures should be used in patients with raised intracranial pressure:
    • head elevation and position,  
    • airway and ventilation control,  
    • sedation and analgesia,  
    • control of fever,  
    • control of hypertension, and  
    • prevention of seizures.
  • Currently, no evidence supports the use of hyperventilation in this setting.

Treatment

  • For raised intracranial pressure, pending neurosurgical procedure only:
    • Give Mannitol 15-25%, IV, 0.25-1 g/kg administered over 30-60 minutes. Monitor neurological response and urine output. Do not repeat more than 6-8 hourly.
    • Beware of hypovolaemia and electrolyte disturbances, especially hypokalaemia.

Currently no evidence exists to support the use of hypertonic saline infusion.

Corticosteroids used in this setting have a harmful effect

For prevention of seizures:

  • Phenobarbital (loading dose 15-20mg/kg [max 1.2g] IV infused at 25 – 100mg/min [beware of respiratory depression at maximum dose]; maintenance dose 13mg/kg/day PO/IV in 1 or 2 divided doses).
  • Phenytoin (loading dose 15 – 20mg/kg [max 2g] IV at 25mg/min slow IV push [Do not exceed 50mg/min]; maintenance 300 – 400mg/day)