Effects of Hypertonic (10%) Saline in Patients With Raised Intracranial Pressure After Stroke

Abstract

Background and Purpose-The aim of this study was to evaluate the effects of hypertonic saline in stroke patients with increased intracranial pressure (ICP) after conventional therapy with mannitol had failed. Methods-Twenty-two episodes of ICP crisis occurred in 8 patients in whom the standard treatment of 200 mL of 20% mannitol was not effective. ICP crisis was defined as an increase in ICP of 20 mm Hg (nϭ18), pupillary abnormality (nϭ3), or a combination of both (nϭ1). The patients were treated with 75 mL of 10% saline over the course of 15 minutes. ICP, mean arterial blood pressure, and cerebral perfusion pressure were monitored for 4 hours. Blood gases, hematocrit, hemoglobin, pH, osmolarity, and electrolytes levels were measured before and 15 and 60 minutes after the start of infusion. Treatment was regarded as effective if ICP decreased Ͼ10% or the pupillary reaction had normalized. Results-Treatment was effective in all 22 episodes. The maximum ICP decrease was 9.9 mm Hg 35 minutes after the start of infusion. Thereafter, ICP began to rise again. There was no constant effect on mean arterial blood pressure, whereas cerebral perfusion pressure was consistently increased. Blood osmolarity rose by 9 mmol/L and serum sodium by 5.6 mmol/L. Potassium levels, hemoglobin, hematocrit, and pH were slightly decreased. No unexpected side effects were noted. Conclusions-Infusion of 75 mL hypertonic (10%) saline decreases elevated ICP and increases cerebral perfusion pressure in stroke patients in whom mannitol had failed. The effect on the ICP and cerebral perfusion pressure reaches its maximum after the end of infusion and is seen for 4 hours.

Current Opinions on Epidemiology, Treatment and Outcome After Traumatic Brain Injury

“…By drawing water into the blood vessels, blood viscosity is reduced, further increasing perfusion [68]. Besides its cerebral therapeutic mechanism mannitol is known as diuretic agent [78]. Therefore, volume replacement might commonly be required increasing potential risks of rebound ICP increase due to a reversed osmolar gradient [78].…”

“…Besides its cerebral therapeutic mechanism mannitol is known as diuretic agent [78]. Therefore, volume replacement might commonly be required increasing potential risks of rebound ICP increase due to a reversed osmolar gradient [78]. Hyperosmolar saline acts similar to mannitol (3-3.4%), as it also creates an osmolar gradient across the blood brain barrier [58,78].…”

“…Therefore, volume replacement might commonly be required increasing potential risks of rebound ICP increase due to a reversed osmolar gradient [78]. Hyperosmolar saline acts similar to mannitol (3-3.4%), as it also creates an osmolar gradient across the blood brain barrier [58,78]. Several studies indicate that its effect is even enhanced compared in mannitol [79,80].…”

Variation in Osmotic Response to Sustained Mannitol Administration

“…There remain cases where mannitol is ineffective at controlling intracranial hypertension (4,18). Such "mannitol resistant" patients may also manifest a failure of their serum sodium and osmolality to rise as expected.…”

“…It has been consistently shown to reduce intracranial pressure (ICP) (1,2). However, there is currently growing interest in hypertonic saline as an alternative to mannitol (3)(4)(5).…”