The Role of Osmotic Therapy in Hemispheric Stroke

• Published in: Neurocritical care Vol. 23; no. 2; pp. 285 - 291
• Main Authors: Ong, C. J., Keyrouz, S. G., Diringer, M. N.
• Format: Journal Article
• Language: English
• Published: New York Springer US 01-10-2015; Springer Nature B.V
• Subjects: Aged; Brain Edema - drug therapy; Brain Edema - mortality; Cardiac arrhythmia; Cerebral Infarction - drug therapy; Cerebral Infarction - mortality; Critical Care Medicine; Diuretics, Osmotic - administration & dosage; Diuretics, Osmotic - pharmacology; Edema; Female; Heart failure; Humans; Intensive; Internal Medicine; Male; Mannitol - administration & dosage; Mannitol - pharmacology; Medical records; Medicine; Medicine & Public Health; Middle Aged; Neurology; Original Article; Outcome Assessment (Health Care); Regression analysis; Retrospective Studies; Saline Solution, Hypertonic - administration & dosage; Saline Solution, Hypertonic - pharmacology; Stroke; Stroke - drug therapy; Stroke - mortality; Success; Malignant edema; Herniation; Cerebrovascular accident; Stroke; Hemicraniectomy
• ISSN: 1541-6933; 1556-0961
• DOI: 10.1007/s12028-015-0173-2

Background
Decompressive hemicraniectomy (DHC) can be lifesaving in hemispheric stroke complicated by cerebral edema. Conversely, osmotic agents have not been shown to improve survival, despite their widespread use. It is unknown whether medical measures can similarly confer survival in certain patient subgroups. We hypothesized that osmotic therapy (OT) without DHC may be associated with a greater likelihood of survival in particular populations depending on demographic, radiologic, or treatment characteristics.
Methods
We performed a retrospective cohort analysis of patients with large anterior circulation strokes with an NIH stroke scale (NIHSS) ≥10 who received OT. We compared clinical, radiologic, and treatment characteristics between two groups: (1) those who survived until discharge with only OT (medical management success) and (2) those who required either DHC or died (medical management failure).
Results
Thirty patients met eligibility criteria. Median NIHSS was 19 [interquartile range (IQR) 13–24], and median GCS was 10 [IQR 8–14]. Forty-seven percent of the medical management cohort survived to discharge. Demographic characteristics associated with medical management success included NIHSS (
p
 = 0.009) and non-black race (
p
 = 0.003). Of the various interventions, the administration of OT after 24 hours and a smaller hypertonic saline dose was also associated with survival to discharge (
p
 = 0.038 and 0.031 respectively).
Conclusion
Our results suggest that patients with moderate size hemispheric infarcts on presentation and those who do not require OT within the first 24 h of stroke may survive until discharge with medical management alone. Black race was also associated with conservative management failure, a finding that may reflect a cultural preference toward aggressive management. Further prospective studies are needed to better establish the utility of medical management of hemispheric edema in the setting of moderate size hemispheric infarcts.