Abstract
The main goals of therapeutic management in patients with acute brain injury (ABI) are to maintain cerebral perfusion pressure (CPP), promote cerebral oxygenation, reduce cerebral edema, prevent intracranial hypertension, and minimize acute neuronal injury in order to limit secondary brain damage. In this context, fluid management is of vital importance, as hypotension and hypovolemia are common in patients with ABI, predisposing them to secondary injury and poorer outcomes, and often necessitating a more liberal fluid strategy. On the other hand, ABI frequently leads to lung injury (LI), including neurogenic pulmonary edema (NPE) and acute respiratory distress syndrome (ARDS), which typically require a conservative fluid strategy to limit pulmonary edema, thereby making fluid resuscitation a significant clinical challenge. Hypervolemia and fluid overload are associated with serious complications, including worsening cerebral edema, delayed ischemic deficits, hemorrhagic diathesis, congestive heart failure, and pulmonary edema. Evidence to guide fluid management strategies in patients with concomitant ABI and ARDS remains limited. Current guidelines recommend targeting normovolemia in patients with ABI using a multimodal approach, with primary endpoints such as arterial blood pressure and fluid balance, while avoiding a negative fluid balance. In these patients, an individualized fluid therapy based on hemodynamic and clinical parameters, as well as cerebral dynamics, is recommended, taking into account the disease course and the potential ARDS subphenotypes.