Review Article

Cerebral Edema and its Management

Lt Col SK Jha (Retd)

MJAFI 2003; 59 : 326-331

Introduction acid provides a supply of damaging molecules [2]. Nitric

oxide (NO) is also a source of free radicals.
S urprising as it may sound cerebral edema is a fairly
common pathophysiological entity which is
encountered in many clinical conditions. Many of these
Macrophages and activated microglial cells form NO
through the action of inducible or immunological NO
conditions present as medical and surgical emergencies. synthetase (iNOS) [2].
By definition cerebral edema is the excess accumulation During injury and ischaemia of the central nervous
of water in the intra-and/or extracellular spaces of the system (CNS) mediators like glutamate, free fatty acids,
brain [1]. or high extracellular potassium compounds are released
or activated, which cause secondary swelling and
Pathophysiology
damage of nerve cells. Other substances like histamine,
Pathophysiology of cerebral edema at cellular level arachidonic acid and free radicals including NO may
is complex. Damaged cells swell, injured blood vessels also be considered mediators of brain edema, but to each
leak and blocked absorption pathways force fluid to enter of these compounds evidence is less clear than for
brain tissues. Cellular and blood vessel damage follows bradykinin (BK) [4]. A variety of mediators may
activation of an injury cascade. The cascade begins enhance each other in a cascading manner by various
with glutamate release into the extracellular space. initiating reactions that might be amenable to
Calcium and sodium entry channels on cell membranes pharmacologic inhibition. BK may be involved in edema
are opened by glutamate stimulation. Membrane ATPase formation after cold lesion, concussive brain injury,
pumps extrude one calcium ion exchange for 3 sodium traumatic spinal cord and ischaemic brain injury.
ions. Sodium builds up within the cell creating an osmotic
In stroke, the molecular cascade initiated by cerebral
gradient and increasing cell volume by entry of water.
ischaemia includes the loss of membrane ionic pumps
Increase in water causes dysfunction but not necessarily
and cell swelling. Secondary formation of free radicals
permanent damage. Finally, hypoxia depletes the cells’
and proteases disrupts brain-cell membranes, causing
energy stores disabling the sodium - potassium ATPase
irreversible damage [5].
and reducing calcium exchange [2].
To explain the consequences of cerebral edema in
Because of failure of the energy-dependent sodium
the simplest terminology, it is best to take the help of
pump in the cellular membrane, sodium accumulates
Monro-Kelie hypothesis, which says that the total bulk
intracellularly and water moves from the extracellular
of three elements (inside the skull) i.e. brain - 1400 ml,
to the intracellular space to maintain osmotic equilibrium
cerebral spinal fluid (CSF) 150 ml
[3]. Calcium accumulates inside the cell activating
and blood 150 ml is at all times constant. Since skull is
intracellular cytotoxic processes. An inflammatory
like a rigid box which cannot be stretched - if the volume
response is initiated by the formation of immediate early
of one of these components increases, it will force the
genes such as c-foc and c-jun and cytokines and other
reduction of volume of the other components. So if
intermediary substances. Microglial cells are activated
there is excessive water, the volume of brain as well as
and release free radicals and proteases which contribute
blood inside the skull is compressed. Conversely,
to the attack on cell membranes and capillaries. Once
primary blood flow disturbances also lead to brain edema
the membranes are disrupted recovery of the cells is
[6]. As the brain, blood or CSF volumes continue to
impossible [2].
increase, the accommodative mechanisms fail and
Free radicals are toxic to cells. Reactive oxygen intracranial pressure (ICP) then rises exponentially.
species such as superoxide ion, hydrogen peroxide and Greatly raised ICP eventually causes a reduction in
hydroxyl ion are produced by the arachidonic acid cerebral blood flow throughout the brain. In its most
cascade. Release of fatty acids such as arachidonic severe form the widespread ischaemia produces brain

Neurology Clinic, B-27, Shri Krishna Puri, Patna, Bihar.

Cerebral Edema 327

death. Lesser degrees of increased ICP and reduced Brain tumours

blood flow can cause correspondingly less severe but Meningitis and encephalitis of all etiologies
still extensive cerebral infarction. The numerical
Other brain infections like cysticercosis, tuberculosis and
difference between raised ICP and mean blood pressure
toxoplasma.
within the cerebral vessels, termed cerebral perfusion
pressure and the duration of its reduction are the main Non-neurological conditions -
determinants of cerebral damage [7]. If these changes Diabetic ketoacidosis, lactic acidotic coma
continue further, it leads to the disastrous condition of Malignant hypertension, hypertensive encephalopathy
brain herniation, which is the forerunner of irreversible Fulminant viral hepatitis, hepatic encephalopathy, Reye’s
brain damage and death. It must be clearly understood syndrome
that though raised ICP is the result of cerebral edema
of significant magnitude, they are not synonymous as Systemic poisoning (carbon monoxide and lead)
raised ICP can be caused by other mechanisms also. Hyponatraemia, SIADH
Types Opioid drug abuse and dependence
Klatzo specified two categories of cerebral edema - Bites of certain reptiles and marine animals
vasogenic and cytotoxic edema. The term cellular edema High altitude cerebral edema (HACO)
refers to cytotoxic edema and is preferable to the latter; Clinical Features
Fishman accepts these two categories but adds a third,
A high index of suspicion is very important. The
which he calls interstitial cerebral edema. Rarely is the
features of cerebral edema add on to and often
separation into distinct categories possible, there is often
complicate the clinical features of the primary underlying
overlap between the various types of edema [2].
condition. Until the ICP reaches a level that produces
Vasogenic cerebral edema refers to the influx of fluid local ischaemia, cerebral edema alone will not produce
and solutes into the brain through an incompetent blood- clinical neurological abnormalities [1]. In a given clinical
brain-barrier (BBB) [3]. This is the most common type setting, alteration in level of consciousness, appearance
of brain edema and results from increased permeability of bradycardia, rise in blood pressure, abnormal breathing
of the capillary endothelial cells, the white matter is patterns evidence of extra ocular movement
primarily affected. Breakdown in the blood-brain barrier abnormalities, alteration and inequality of pupillary size
allows movement of proteins from the intravascular and extensor plantar response on the side of the lesion
space through the capillary wall into the extracellular should raise strong suspicion of cerebral edema.
space.
The most common cause of neurological deterioration
Cellular (cytotoxic) cerebral edema refers to a cellular and death during acute ischaemic stroke is cerebral
swelling [3]. It is seen in conditions like head injury and edema. It occurs in all ischaemic strokes. Ischaemic
hypoxia. It results from the swelling of brain cells, most brain edema is initially cytotoxic because of disturbances
likely due to the release of toxic factors from neutrophils in cell membrane. Later vasogenic edema sets in due
and /bacteria. Cytotoxic edema is caused by swelling to disruption of BBB [8]. Cerebral edema usually begins
of glia, neurons, endothelial cells and begins within to develop soon after the onset of ischaemia and peaks
minutes after an insult. Cytotoxic edema affects at 24-96 hours. Usually this is confined to ischaemic
predominantly the gray matter [3]. region and does not appreciably affect adjacent brain.
Interstitial edema is seen in hydrocephalus when But, when it progresses it compresses brain regions
outflow of CSF is obstructed and intraventricular adjacent to ischaemic zone causing neurological
pressure increases. The result is movement of sodium worsening.
and water across the ventricular wall into the
Investigations
paraventricular space [3]. Interstitial cerebral edema
occurring during meningitis is due largely to obstruction CT scan provides an excellent tool for in vivo
of normal CSF pathways, with a resulting increase in determination of abnormalities in brain water content.
the resistance to CSF outflow. The areas of edema appear as low density on
unenhanced scan. This is due to the dilution of all the
Etiology constituents of the white matter [1]. The anatomical
Cerebral edema is seen in the following neurological specificity of CT permits detection of not only the
and non-neurological conditions: presence but also the type of brain edema. This is helpful
Neurological conditions - in differentiating nature of underlying lesion eg.
Ischaemic stroke and intracerebral haemorrhage infarction/tumour. In general, the more malignant

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328 Jha

primary tumours of the brain and metastatic tumours by decreasing water content. Mannitol may also improve
entail the greatest incidence of cerebral edema, although cerebral perfusion by decreasing viscosity or altering
presence of brain edema does not rule out benign lesions. red blood cell rheology. Lastly, mannitol may exert a
CT is an excellent method for following the resolution protective effect against biochemical injury [10].
of brain edema following therapeutic intervention. There is some evidence that lower dosage is quite
Cerebral edema in acute vascular lesions can be seen effective with less chances of inducing hyperosmolar
in both the cortex and the underlying white matter. The problems that have been noted with frequent high-dose
cerebral edema in an epidural and intracerebral therapy [1]. IV Mannitol is given in the dosage of 1.0
haematoma is typically limited to white matter [1]. g/kg, then 50 g every 2-3 hours [9]. When Mannitol is
MRI appears to be more sensitive than CT at used, one should aim for plasma osmolality 300-310
detecting brain abscess in the cerebritis phase of its mOsm/L with maintenance of adequate plasma volume
development as well as at detecting associated cerebral [8]. Prolonged administration of Mannitol results in an
edema. electrolyte imbalance that may override its benefits and
ICP monitoring is an important tool to monitor cases that must be carefully monitored [2]. Nursing care of
where cerebral edema is present or anticipated and is the patient receiving Mannitol requires vigilant monitoring
routinely done in all Neurology and Neurosurgery ICUs. of electrolytes and overall fluid balance and observation
Unfortunately, the direct measurement of ICP and for the development of cardiopulmonary complications
aggressive measures to counteract high pressures have in addition to neurological assessment [10].
not yielded uniformly beneficial results, and after two Glycerol is another useful agent given in oral doses
decades of popularity - the routine use of ICP monitoring of 30 ml every 4-6 hour or daily IV 50g in 500 ml of
remains controversial. The problem may be partly a 2.5% saline solution although its effectiveness appears
matter of the timing of monitoring and the proper selection to decrease after few days. It is used in a dose of 0.5-
of patients for aggressive treatment of raised ICP. Only 1.0 g/kg body weight. In unconscious or uncooperative
if the ICP measurements are to be used as a guide to patients it is given by nasogastric tube [1].
medical therapy and the timing of surgical 2. Diuretics - The osmotic effect can be prolonged
decompression, is the insertion of a monitor justified [7]. by the use of loop diuretics (Furosemide) after the
Whether ICP monitoring adds much to the management osmotic agent infusion. Loop diuretics (Furosemide)
of patients of stroke is still open to question, clinical can be used as an adjunct. Furosemide (0.7 mg/kg) has
signs and imaging data on shift of brain tissue are been shown to prolong the reversal of blood brain osmotic
probably more useful [9]. gradient established with the osmotic agents by
EEG is not very helpful in the management of cerebral preferentially excreting water over solute [1].
edema, because the changes which are noted are the 3. Corticosteroids - Corticosteroids lower
sum total of changes due to cerebral edema, raised ICP intracranial pressure primarily in vasogenic edema
and the primary lesion superimposed upon each other. because of their beneficial effect on the blood vessel.
Treatment They have been less effective in cytotoxic edema, and
are not recommended in treatment of edema secondary
Treatment of brain edema has not kept up with the
to stroke or haemorrhage. In fact, systemic
advances in understanding of the mechanism producing
complications of steroids can worsen the patient’s
the edema [2].
condition [2]. Corticosteroids have not proven effective
Medical treatment in stroke unless stroke is caused by documented cerebral
1. Osmotherapy vasculitis. Inj Dexamethasone 4-6 mg IM every 4-6 hours
The most rapid and effective means of decreasing may be useful in these cases. They have also been used
tissue water and brain bulk is osmotherapy [1]. Osmotic in chronic meningitis and in acute bacterial meningitis
therapy is intended to draw water out of the brain by an under cover of antibiotics. Glucocorticoids are used for
osmotic gradient and to decrease blood viscosity. These the management of malignant brain tumours, either
changes would decrease ICP and increase cerebral primary or secondary, as adjuvant chemotherapy of some
blood flow (CBF). CNS tumours and perioperatively in brain surgery.
Edema surrounding brain tumours particularly metastatic
Mannitol is the most popular osmotic agent. Osmotic brain tumours responds dramatically to treatment with
therapy using mannitol reduces ICP by mechanisms that high doses of Dexamethasone [2]. Glucocorticoids are
remain unclear. Mannitol is thought to decrease brain believed to exert their influence on brain tumours mainly
volume by decreasing overall water content, to reduce by reducing tumor-associated vasogenic edema, probably
blood volume by vasoconstriction, to reduce CSF volume by decreasing the increased capillary permeability of
MJAFI, Vol. 59, No. 4, 2003
Cerebral Edema 329

BBB. The role of corticosteroids in head trauma is measures for management should be initiated.
uncertain [2]. Position of the patient - Elevation of head end of bed
4. Hyperventilation - Controlled hyperventilation is 15-30 degrees to promote cerebral venous drainage is
helpful in reducing the raised ICP. The cerebral advisable and head is kept in midline to limit neck vein
vasculature is most sensitive to arterial pCO2 changes compression. However, in acute carotid or basilar artery
around the normal level of 40 mm Hg. ICP falls within occlusion bed is not tilted to avoid hypoperfusion distal
minutes of onset of hyperventilation and although the to occlusion [8].
buffering mechanisms in the CSF and extra cellular fluid Correction of contributory factors - Correction of
soon restore pH to normal the effect may last for many factors increasing ICP e.g. hypercarbia, hypoxia,
hours. It is important to monitor the effects of ventilation hyperthermia, acidosis, hypotension and hypovolaemia
carefully by blood gas analysis and chest radiograph. is helpful. Endotracheal intubation and mechanical
The pCO2 should not be reduced below 25 mm Hg. At ventilation to hyperventilate to PaCO2 of 25 mm Hg is
this point vasoconstrictor effect of hypocarbia itself will helpful in impending herniation [8].
cause hypoxia and ischaemic cell damage [11].
Fluid restriction - Fluid restriction minimally affects
5. Other agents - Barbiturates, Procaine derivatives, cerebral edema and, if pursued to excess, may result in
Indomethacin, Propofol and THAM (Thrometamine) are episodes of hypotension, which may increase ICP and
some other agents which have been tried and used in is associated with worse neurologic outcome [16].
the past but are not being used routinely in present Glucose containing solutions should be avoided;
practice [12,13,14]. euvolaemia should be maintained, N or N/2 saline should
Barbiturates produce a marked decrease in metabolic be used; urinary losses should be replaced with N saline
rate and it seems likely that the fall in cerebral blood in patients receiving Mannitol [8].
flow and ICP is secondary. Complication of barbiturate Hypothermia - Multiple mechanisms for reduced brain
therapy, in particular systemic hypotension and temperature-induced neuroprotection have been
pulmonary failure, have caused concern and careful identified and include reduced metabolic rate and energy
monitoring with a Swan Ganz catheter is recommended depletion, decreased excitatory transmitter release,
[11]. reduced alterations in ion flux, reduced vascular
Lidocaine will prevent a rise in ICP during intubation. permeability, edema and BBB disruption [17]. Recent
It may act directly on brain stem vasomotor centre. studies have led to the hypothesis that changes in post-
However, there is no present evidence that it reduces ischaemic cerebral temperature can critically modulate
ICP already raised [11]. THAM has been used to encephalopathic processes which are initiated during the
regulate the acidotic impairment of cerebral primary phase of hypoxia-ischaemia, but which extend
autoregulation and the response of the vascular system into the secondary phase of cerebral injury. Randomised
to hypocapnia can be improved [13]. clinical trials are in progress to establish the safety and
efficacy of prolonged cerebral hypothermia [18]. Suarez
Surgical treatment
JI has shown that a body temperature >37.5°C and blood
Surgical treatment is occasionally recommended for glucose >150 mg/dl are related to worsening of the
large hemispherical infarcts with edema and life cerebral edema. The measures necessary for good
threatening brain-shifts. Temporary venticulostomy or cerebral reanimation are the following : evaluation of
craniectomy may prevent deterioration and may be the airway, controlled hyperventilation, maintenance of
lifesaving. Decompressive craniectomy in the setting the cerebral perfusion pressure >70 mm Hg, suitable
of acute brain swelling from cerebral infarction is a life position of the head, administration of hypertonic
saving procedure and should be considered in younger solutions, Dexamethasone, and possibly barbiturates
patients who have a rapidly deteriorating neurological [19].
status [15]. Also, in large cerebellar infarcts with
Blood pressure needs to be monitored carefully in
cerebral edema surgical decompression is life saving
cases with cerebral edema. When cerebral edema
[16]. The surgical removal of lesions responsible for
causes raised ICP, systemic blood pressure rises as a
cerebral edema results in resolution of cerebral edema.
compensatory phenomenon to ensure adequate cerebral
In cases of severe hydrocephalus VP shunt is very
perfusion. Hence, under these circumstances bringing
helpful [1].
down the raised blood pressure will increase the extent
General measures of cerebral ischaemic damage and will be counter
When signs of elevated ICP are present certain productive.

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330 Jha

Management of cerebral edema in specific In children, cerebral edema is a common cause of death
conditions (less frequent in adults). The exact cause of the brain
swelling is not known, however, in a recent study Glaser
Stroke
et al found that children with diabetic ketoacidosis with
In stroke 5% - 10% patients develop symptomatic low partial pressures of arterial carbon dioxide and high
cerebral edema resulting in obtundation with its attendant serum urea nitrogen and treatment with bicarbonate
consequences or brain herniation. Edema peaks on the therapy are at an increased risk of cerebral edema [24].
second or third day but causes mass effect for 10 days. Theories include osmotic disequilibrium between brain
The larger the infarct, the more likely edema will be a and plasma as glucose is rapidly lowered, decreased
problem. Even small amounts of edema from a cerebellar plasma oncotic pressure due to infusion of large amounts
stroke can raise intracranial pressure in the posterior of saline, and insulin-inducted ion flux across the BBB.
fossa. Restriction of free water and intravenous Mannitol Whatever the mechanism, mortality rates are high.
may be useful [3]. As the molecular events become Treatment involves the bolus infusion of 1 g Mannitol
clearer, novel treatments that block different stages of per kilogram of body weight in the form of 20% solution.
the injury cascade will be available for clinical testing The major nonembolic complication of DKA therapy is
[5]. cerebral edema, which most often develops in children
Cerebral edema in bacterial meningitis as DKA is resolving. The etiology and optimal therapy
Initial management of increased ICP is intubation and for cerebral edema are not well established but over
controlled hyperventilation to reduce pCO2 to 25 mm replacement of free water should be avoided.
Hg [20]. However, the effect of hyperventilation is Reye’s syndrome (Fatty Liver with
transient. Hypotension should be avoided to maintain Encephalopathy)
cerebral perfusion. Mannitol may enter brain through Fatty changes of the renal tubular cells, cerebral
partially open BBB and therefore is less effective. edema, and neuronal degeneration of the brain are the
Corticosteroids have shown no benefit in 24 hours over major extra hepatic changes in Reye’s syndrome.
non-corticosteroid treated patients. Lasix and fluid Therapy consists of infusion of glucose and fresh frozen
restriction produces dehydration, fall of blood pressure, plasma, as well as intravenous. Mannitol to reduce the
low cerebral perfusion pressure and increased risk of cerebral edema [25].
cerebral thrombosis. If severe hydrocephalus is present
VP shunt should be considered [8]. Cirrhosis of Liver
Cerebral edema is frequently present and contributes
Tuberculous Meningitis and Tuberculoma
to the clinical picture and overall mortality in patients
Glucocorticoids are a useful adjunct to chemotherapy, with both acute and chronic encephalopathy.
clinical trials have demonstrated that patients treated Hemoperfusion to remove toxic substances and therapy
with adjunctive glucocorticoids experience a significantly directed primarily towards coincident cerebral edema
faster resolution of CSF abnormalities and elevated CSF in acute encephalopathy are also of unproven value [26].
pressure. Adjunctive glucocorticoids enhance survival
and reduce the frequency of neurologic sequelae High Altitude Cerebral Edema
especially in cases with cerebral edema [21]. High altitude cerebral edema is a clinical diagnosis,
defined as the onset of ataxia, altered consciousness, or
Toxoplasmosis
both, in someone with acute mountain sickness or high
Glucocorticoids are recommended for the altitude pulmonary edema [27]. Global encephalopathy
management of patients with cerebral edema [22]. rather than focal findings, characterizes high - altitude
Cryptococcosis cerebral edema [27]. Despite normal cerebral
Daily lumbar puncture or CSF shunting has been oxygenation and normal global cerebral metabolism,
advocated in the hope of averting permanent blindness vasogenic edema develops in humans (and sheep) who
for patients with marked cerebral edema who have become moderately ill with acute mountain sickness /
incipient blurred vision [23]. high altitude cerebral edema during 24 hour or more of
hypoxic exposure [28]. The exact cause of high altitude
Diabetic Ketoacidosis cerebral edema is not known. Possible mediators, some
When the plasma glucose level falls to about 17 mmo1/ triggered by endothelial activation, include vascular
L (300 mg/dL), 5% glucose solutions should be added, endothelial growth factor, inducible nitric oxide synthase
both as a source of free water and as a prophylactic and bradykinin [27].
measure to prevent the late cerebral edema syndrome. Treatment requires descent and gradual

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acclimatization provides the most effective prevention 12. de los Reyes RA, Ausman JI, Dias FG. Agents for cerebral
[29]. Acetazolamide is an effective preventive aid and edema. Clin Neurosurg 1981;28:98-107.
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Klatzo I, Spatz M, editors. Brain edema. Proceedings of sixth
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16. Zornow MH, Prough DS. Fluid management in patients with
Though there has been good progress in our traumatic brain injury. New Horiz 1995;3:488-98.
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associated with cerebral edema more effective treatment transient focal ischemia provides complete neuroprotection.
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agent for the treatment of cerebral edema- one that 18. Gunn AJ, Gunn TR. The ‘pharmacology’ of neuronal rescue
would selectively mobilize and / or prevent the formation with cerebral hypothermia. Early Hum Dev 1998;53(1):19-
of edema fluid with a rapid onset and prolonged duration 35.
of action, and with minimal side effects, remains to be 19. Suarez JI. Treatment of acute brain edema. Rev Neurol
discovered. Probably in the days to come we can look 2001;32(3):275-81.
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