Introduction: Malignant cerebral edema, present in many conditions, is of particular interest in the treatment of acute stroke. Usually peaking around three days after a large volume stroke, cytotoxic edema can produce significant mass effect for up to ten days. Hyperosmolar therapy is the primary medical management, but is often looked upon as a temporizing measure. Several studies have indicated early decompressive craniectomy provides better outcomes.[cite hamlet, decimal, stroke trials here] We sought to analyze the effects of aggressive medical management with hypertonic saline therapy on morbidity, mortality, length of stay, and frequency of surgical intervention.
Methods: A retrospective chart analysis was performed for patients at a single institution from November 2014 to May 2017. Variables included demographics, GCS and NIH upon ED presentation, type of hypertonic used (continuous infusion or 23.4% bolus), sodium value on arrival, target sodium, length of time to achieve target sodium, requirement of surgical intervention, and mortality. Statistical comparison made between variables using Students’ T-Test.
Results: Data from 108 patients were collected. 11 patients were excluded due to incomplete records. There were 65 males and 43 females with an age range of 25 to 92 years old. Regarding mortality, GCS (p=.0427) and NIH (p=.0017) scores were found to be of clinical significance. Further analysis showed that no variables exhibited statistical significance when determining which patients required surgical intervention throughout their stay.
Conclusions: Our results show the most important factors necessitating surgical intervention and mortality were GCS and NIH scores upon presentation, serving as surrogate markers for patient status before therapy initiation. Hypertonic therapy did not reduce the number of patients requiring decompressive craniectomy and did not affect overall mortality. Additional analysis regarding individualized care, including individualized sodium goals and bolus or continuous hypertonic treatment might elucidate a more effective nonsurgical treatment regimen.
Patient Care: This will set the framework for further research to identify factors involved in patient selection for early craniectomy or medical management of large territory strokes, management of malignant cerebral edema in stroke, and to hopefully identify factors that can modify and individualize treatments to provide greater benefit to specific patient populations
Learning Objectives: To better understand criteria involved in selecting appropriate patients for early surgical intervention to avoid mortality and to better select patients for hypertonic treatment.