Measures to lessen the risk of swelling and close monitoring of the patient for signs of neurological worsening during the first days after stroke are recommended. Early transfer of patients at risk for malignant brain swelling to an institution with appropriate neurosurgical expertise should be considered. I C-LD Recommendation reworded for brevity and consistency from 2013 AIS Guidelines. LOE revised. See Table XCV in online Data Supplement 1 for original wording. 5.1.2. Medical Management COR LOE New, Revised, or Unchanged Use of osmotic therapy for patients with clinical deterioration from brain swelling associated with cerebral infarction is reasonable. IIa C-LD Recommendation reworded for clarity from 2014 Brain Swelling. COR unchanged. LOE amended to conform with ACC/AHA 2015 Recommendation Classification System. See Table XCV in online Data Supplement 1 for original wording. Use of brief moderate hyperventilation (Pco2 target, 30 34 mmHg) is a reasonable treatment for patients with acute severe neurological decline from brain swelling as a bridge to more definitive therapy. IIa C-LD New recommendation. A single nonrandomized study of 3 days of sustained hyperventilation in AIS designed primarily to investigate physiological changes showed no difference in mortality.281 Data on the use of hyperventilation for the management of increased intracranial pressure from patients with traumatic brain injury show a rapid reduction in intracranial pressure with return toward baseline over the next few hours.282 284 The only RCT of sustained hyperventilation in traumatic brain injury demonstrated that prophylactic hyperventilation for 5 days was associated with worse outcomes.285 See Tables LXXI and LXXII in online Data Supplement 1. Hypothermia or barbiturates in the setting of ischemic cerebral or cerebellar swelling are not recommended. III: No Benefit B-R Recommendation and LOE revised from 2014 Brain Swelling. COR amended to conform with ACC/AHA 2015 Recommendation Classification System. 