Elevated ICP or Cerebral Edema in Acute Ischemic Stroke — When Mannitol Has Not Achieved an Adequate Response

Acute ischemic stroke can be complicated by elevated intracranial pressure or cerebral edema requiring prompt osmotic intervention. When the initial agent does not achieve adequate reduction of ICP and edema, a defined next step is indicated.

Clinical Scenario

Acute ischemic stroke with elevated intracranial pressure or cerebral edema, in a patient who has received initial osmotherapy but has not had an adequate treatment response.

Prior Treatment — Inadequate Response

Initial management with mannitol (intravenous) was used to reduce elevated intracranial pressure and cerebral edema. The target — reduction of elevated intracranial pressure and cerebral edema — was not adequately reached, warranting escalation to this protocol.

Next-Step Treatment Approach

For patients in this setting who have not responded adequately to mannitol, intravenous hypertonic sodium solution therapy is the agent considered at this stage. The complete selection criteria, regimen, and guidance are in the full protocol.

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References

DOI: 10.1007/s12028-020-00959-7

We suggest using either hypertonic sodium solutions or mannitol for the initial management of ICP or cerebral edema in patients with acute ischemic stroke (conditional recommendation, low-quality evidence).

We suggest that clinicians consider administration of hypertonic sodium solutions for management of ICP or cerebral edema in patients with acute ischemic stroke who do not have an adequate response to mannitol (conditional recommendation, low-quality evidence).

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