What is your approach to management of patients with cerebral edema in the setting of hypoxic-ischemic injury?

Depends on the clinical status of the patient. Obviously, if the neurological exam is modestly good, i.e., purposeful movement or better, then follow the exam for signs of worsening edema. If the exam is not so good (flexion or less), we tend to use continuous EEG and serial imaging to monitor.

As for treatment, I haven't found much to be successful. So don't really treat beyond supportive care unless there are signs of herniation. If the exam has been poor since presentation and the patient develops signs of herniation, often goals of care discussion is in order. If there's evidence of herniation and aggressive care is indicated, then my approach is the same for any herniation syndrome with modest hyperventilation & hyperosmolar therapy. But again, I haven't found this to be very successful.

This depends on multiple factors, including clinical exam, extent of edema seen on imaging, and time from ictus. If the patient has a reasonable clinical exam that can be followed, they can be monitored. If the imaging reveals early diffuse cerebral edema with a poor exam but not complete loss of brainstem reflexes, it is reasonable to treat with hypertonics to assess improvement. This generally means a targeted sodium goal, as most of these patients do not receive ICP monitors. There are no tried-and-true treatment options in this situation, and it is reasonable to err on the side of treatment if the patient is at risk for herniation based on clinical and imaging studies.