1. Management of Brain edema 하 상 우하 상 우 조선대학교병원 신경외과학교실

2. IntroductionJournal reviewText reviewConclusion Intensive care unit of Neurosurgery Brain TumorVascularFunctionalPediatricTrauma SpinePeripheral ICP control Post Op. care

3. IntroductionJournal reviewText reviewConclusion Intracranial pressure (ICP) Normal ICP : 7~15mmHg (10-20 cmH2O) ICP = CSF pressure : defined as the pressure against a needle introduced into the CSF space : depends on several parameters Atmosphere pressure ignored Hydrostatic pressure weight of fluid and tissue above the point of measurement (Position 차이 ) Filling pressure defined by volume of the intracranial contents & elastance of the enclosing structures Filling pressure

4. IntroductionJournal reviewText reviewConclusion General physiology of CSF Intracranial space : 1500mL : Brain 87%, CSF 9%, blood 4% : Extracellular space : 15% of total brain volume CSF volume : mean 164.5 mL (62.2-267) ▶ 150 mL Ventricular volume : mean 31.9 mL (7.49-70.5) ▶ 30mL CSF production : Choroid plexus, Ventricular ependyma (50-100%) Drainage ▶ Dural venous sinus : Arachnoid granulation or villi (valvular connection : No reflux) : Stop, when CSF pressure < 5 mmHg

5. IntroductionJournal reviewText reviewConclusion Monro-Kellie doctrine V CSF + V BLOOD + V BRAIN + V OTHER = V INTRACRANIAL SPACE = 일정하다 !!

6. IntroductionJournal reviewText reviewConclusion Principal types of Brain edema Cytotoxic edema Vasogenic edema Interstitial edema Osmotic edema Infarction, Trauma…Brain tumor…Hydrocephalus…Hemodialysis…

7. IntroductionJournal reviewText reviewConclusion Vasogenic edema Increased vascular permeability at the level of the blood brain barrier, with extracellular fluid accumulation Composition of edema : ultrafiltrate of plasma Location of edema : White matter ECF volume : ▲ (Extracellular edema) Etiology : Brain tumors, Abscess, encephalitis, Infarction (late stage), Lead toxicity, Trauma Response to Tx.  Corticosteroid : Yes !  Diuretics : Minimally or not effective

8. IntroductionJournal reviewText reviewConclusion Cytotoxic edema Osmotic gradient because of metabolic failure of the Na +, K + -ATPase pump, with cellular swelling of all elements Composition of edema : Net intracellular accumulation of Water & Sodium Location of edema : Gray & White matter ECF volume : ▼ (Intracellular edema) Etiology : Anoxia, DKA, Hepatic encephalopathy, Hypothermia, Infarction or Ischemia, infection, meningitis, Trauma, etc. Response to Tx.  Corticosteroid : Not effective  Diuretics : Transiently effective

9. IntroductionJournal reviewText reviewConclusion Difference in Image findings Cytotoxic edema Vasogenic edema ▶ Involve white matter & spare gray matter

10. IntroductionJournal reviewText reviewConclusion Treatment : Surgery, Osmotherapy, Corticosteroid : Mannitol, Glycerol, Hypertonic saline -Typical dose : Mannitol 1g/kg (250mL of a 20% solution in an average adult) ▶ Reduction in ICP of 30 ~ 60% for 2 ~ 4 hours ▶ Massive osmotic diuresis : Fluid and electrolyte balance should be monitored carefully -Negative effects in brain tumor : Enhance disturbance of the blood brain barrier (open tight junction) : Not routinely recommend in patients with brain tumor edema Osmotherapy

11. IntroductionJournal reviewText reviewConclusion Corticosteroids reduce the expression of the edema-producing factor VEGF Rapid edema-reducing effect : 1 hour after a single dose of steroid Dexamethasone : Most commonly used corticosteroid - 6 times as potent as prednisolone (20mg Dexa = 130mg prednisone) - Reaches full effect within 24 ~ 72 hours - Dosage : 4 ~ 100mg/day - Lower mineralocorticoid (salt-retaining) effects than other corticosteroids : Increased risk of hyponatremia (which enhances the generation of edema) Corticosteroids

12. IntroductionJournal reviewText reviewConclusion Side effects Steroid myopathy (catabolic effect of corticosteroid) Cushingoid faces (redistribution of fat from peripheral to central parts) Disturbed glucose metabolism (50%) Peptic ulcer : H2 blockers or proton pump inhibitors is recommended) Pneumocystis carinii pneumonia (2%, life-threatening) + immune compromised ▶ Prophylactic Tx with trimethoprim-sulfamethoxazole Corticosteroids

13. IntroductionJournal reviewText reviewConclusion Withdrawal (Tapering) Corticosteroids should be tapered within 2 ~ 3 weeks : Decreasing the dose by 50% every 4 days is a reasonable approach Poorly controlled tumors or extensive brain edema (deteriorate after rapid tapering) : taper by 25% every 8 days Eventually, chronic treatment with a low dose of corticosteroids (1 ~ 2mg/day) Rapid tapering of corticosteroids ▶ “Steroid withdrawal syndrome” : Arthralgia, Myalgia, Headache, Lethargy, Low-grade fever, etc. ▶ Adrenal insufficiency : weakness, pigmentation of skin, weight loss

14. IntroductionJournal reviewText reviewConclusion Take home message ! Normal ICP : 7-15mmHg (10-20 cmH20) CSF volume : 150 / Ventricle : 30 Monro-kellie doctrine : Volume of Intracranial space 일정 ! Vasogenic edema 와 Cytotoxic edema 의 차이 ! ▶ Vasogenic 은 tumor 같은 상황에서 투과성 변화로 White matter 에만 edema 있고, steroid 에 반응 좋다 ! ▶ Cytotoxic 은 왕창 깨지면서 막 부어오르고, steroid 에 효과 없다 ! Brain tumor 환자들의 edema control 에는 steroid 가 좋은데, 여러 가지 부작용을 고려해서 잘 쓰고 잘 줄여야 한다 ! Trauma, Vascular(Aneurysm, S-ICH, AVM 등 ) 에는 Steroid 효과 X !!