High altitude cerebral edema

Background

Also known as HACE
Progressive neurologic deterioration in someone with acute mountain sickness or HAPE (due to ↑ ICP)
Almost never occurs at <8,000ft

Clinical Features

Altered mental status, ataxia, gait disturbance, stupor (most sensitive findings)
- Progresses to coma if untreated
Uncertain mechanism, presumed cause is hypoxia leading to cerebral edema
Headache, nausea/vomiting (not always present)
Focal neuro deficits may be seen (3rd/6th CN palsies)
Seizures are rare

Differential Diagnosis

High Altitude Illnesses

Evaluation

Head CT of HACE showing diffuse effacement of cerebral sulci and compression of ventricles.

Typically a clinical diagnosis

Expected SpO₂ and PaO₂ levels at altitude[1]

Altitude	SpO₂	PaO₂ (mm Hg)
1,500 to 3,500 m (4,900 to 11,500 ft)	about 90%	55-75
3,500 to 5,500 m (11,500 to 18,000 ft)	75-85%	40-60
5,500 to 8,850 m (18,000 to 29,000 ft)	58-75%	28-40

Management

High altitude management algorithm.

Immediate descent is the treatment of choice
If descent not possible use combination of:
- Supplemental O2 (goal SpO2 90%)[2]
- Supportive hyperventilation
- Dexamethasone 8mg initially (PO, IM, or IV), then 4mg q6hr
- Acetazolamide 250mg BID (better as ppx)
- Hyperbaric bag (Gamow bag) if available

Prevention

Acclimatization, slow ascent
Acetazolamide 125mg BID (250mg BID if greater than 100kg)
Dexamethasone 4mg q6h PO or IV

See Also

High Altitude Medicine

References

Gallagher, MD, Scott A.; Hackett, MD, Peter (August 28, 2018). "High altitude pulmonary edema". UpToDate. Retrieved May 2, 2019.
Hackett PH, Roach RC. High altitude cerebral edema. High Alt Med Biol 2004; 5:136-146.

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