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Hypertonic Saline is Superior to Mannitol for the Combined Effect on Intracranial Pressure and Cerebral Perfusion Pressure Burdens in Patients With Severe Traumatic Brain Injury.

TitleHypertonic Saline is Superior to Mannitol for the Combined Effect on Intracranial Pressure and Cerebral Perfusion Pressure Burdens in Patients With Severe Traumatic Brain Injury.
Publication TypeJournal Article
Year of Publication2020
AuthorsMangat HS, Wu X, Gerber LM, Schwarz JT, Fakhar M, Murthy SB, Stieg PE, Ghajar J, Härtl R
JournalNeurosurgery
Volume86
Issue2
Pagination221-230
Date Published2020 02 01
ISSN1524-4040
KeywordsAdolescent, Adult, Brain Injuries, Traumatic, Case-Control Studies, Cerebrovascular Circulation, Diuretics, Osmotic, Female, Glasgow Coma Scale, Humans, Intracranial Hypertension, Intracranial Pressure, Male, Mannitol, Middle Aged, Prospective Studies, Saline Solution, Hypertonic, Treatment Outcome, Young Adult
Abstract

BACKGROUND: Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their simultaneous effect on the cerebral perfusion pressure (CPP) and ICP has not been studied rigorously.

OBJECTIVE: To determine the difference in effects of HTS and mannitol on the combined burden of high ICP and low CPP in patients with severe TBI.

METHODS: We performed a case-control study using prospectively collected data from the New York State TBI-trac® database (Brain Trauma Foundation, New York, New York). Patients who received only 1 hyperosmotic agent, either mannitol or HTS for raised ICP, were included. Patients in the 2 groups were matched (1:1 and 1:2) for factors associated with 2-wk mortality: age, Glasgow Coma Scale score, pupillary reactivity, hypotension, abnormal computed tomography scans, and craniotomy. Primary endpoint was the combined burden of ICPhigh (> 25 mm Hg) and CPPlow (< 60 mm Hg).

RESULTS: There were 25 matched pairs for 1:1 comparison and 24 HTS patients matched to 48 mannitol patients in 1:2 comparisons. Cumulative median osmolar doses in the 2 groups were similar. In patients treated with HTS compared to mannitol, total number of days (0.6 ± 0.8 vs 2.4 ± 2.3 d, P < .01), percentage of days with (8.8 ± 10.6 vs 28.1 ± 26.9%, P < .01), and the total duration of ICPhigh + CPPlow (11.12 ± 14.11 vs 30.56 ± 31.89 h, P = .01) were significantly lower. These results were replicated in the 1:2 match comparisons.

CONCLUSION: HTS bolus therapy appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients.

DOI10.1093/neuros/nyz046
Alternate JournalNeurosurgery
PubMed ID30877299