Current therapy

Therapy can be classified as treatment for 'brain swelling' (raised ICP) or as specific therapy to reduce edema ( Dea^rdenandMjJlerJQQl). ICP therapy aims to place the cranial contents on a more favorable part of the intracranial compliance curve. Reduction of ICP resulting in improved cerebral perfusion pressure may reduce brain ischemia and help to resolve edema. Cerebral blood volume may be reduced by head-up tilt, hyperventilation, and hypnotic agents. Cerebrospinal fluid volume may be reduced by using intraventricular drainage and will decrease hydrocephalic edema. If ICP reduction improves cerebral perfusion pressure, compromised cerebral blood flow may also be restored.

Diuretics such as furosemide (frusemide) and acetazolamide are not widely employed to reduce the production of cerebrospinal fluid because of unfavorable effects on electrolytes and acid-base balance.

Methods of ICP/edema reduction include osmotherapy, steroids, and manipulation of osmotic and oncotic pressure (D.§§ld.§0...§nd MÍ!iei...l9.9.I). Osmotherapy

Hyperosmotic agents (e.g. mannitol) exert a dehydrating effect on the brain parenchyma. Several mechanisms of action have been proposed.

Hyperosmotic agents build up an osmotic gradient since they are small non-diffusible molecules and therefore water is withdrawn where the blood-brain barrier is intact. In theory they will not work across an impaired blood-brain barrier. However, there is evidence that mannitol works in areas with impaired blood-brain barrier with a reduced effect.

Hyperosmotic agents decrease plasma viscosity and improve the rheological properties of blood and plasma, thereby improving cerebral blood flow. They improve energetic metabolism and acidosis and reduce the spread of edema.

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