Adding Salt to the Wounds: Perceived Risk of Hypertonic Saline for Cerebral Edema

摘要

In the 1974 movie Young Frankenstein, the late great Gene Wilder, portraying the eccentric Dr Frederick Frankenstein, proclaims to his young medical student, "Hearts and kidneys are tinkertoys! I am talking about the central nervous system!"! This indeed is the prevailing philosophy for poststroke cerebral edema management in the neurological intensive care unit (NICU). Large strokes, especially those involving the middle cerebral artery territory, have a high incidence of clinical deterioration due to cerebral edema—which can occur in about two-thirds of cases and be "malignant" or fatal in about half.2 So what is the antidote for cerebral edema? Beyond surgical craniectomy, which is more of a reactive than a proactive measure, the most common medical therapy is either mannitol or hypertonic saline (HTS), both of which have been associated with cardiotoxic and nephrotoxic side effects. Regardless, if these medications are able to mitigate stroke-induced cerebral edema and thereby save patients' brains from swelling and dying, then why would anyone fret about theoretical damage to hearts and kidneys???