Role of Hypertonic Saline for the Management of Intracranial Hypertension After Stroke and Traumatic Brain Injury

Abstract

Increased intracranial pressure after neurologic injury is a clinical challenge that often requires administration of osmotic agents. The most common osmotic agent used for treatment has been mannitol; however, interest has been renewed in using hypertonic saline after neurologic injury, since it is not associated with hypovolemia. The types of procedures or injury for which hypertonic saline has been used are vast, from elective craniotomy for tumor resection to stroke and traumatic brain injury. Unfortunately, there is a paucity of well-controlled clinical trials that provide evidence for the best concentration, administration approach, and length of therapy with hypertonic saline. The bulk of the data exists for traumatic brain injury, although most of these data are from observational and retrospective analyses, which do not allow for an evaluation of the impact of hypertonic saline on clinical outcomes. Nonetheless, both animal and clinical data suggest that patients with traumatic brain injury and those with stroke may benefit from hypertonic saline therapy. Since hypertonic saline has a high risk of injury with inappropriate administration and is considered a "high-alert" drug, safety issues surrounding its dispensing and administration must be considered. Randomized outcome trials comparing mannitol with hypertonic saline in various subpopulations of neurologic injury would add valuable information to the literature and provide a basis for establishment of best clinical practices.

Cardiac output changes after osmotic therapy in neurosurgical and neurocritical care patients: a systematic review of the clinical literature

“…Therefore, enhancement of cardiac performance and optimization of fluid balance, could improve brain perfusion especially in patients with impaired cardiac function [30,31]. Infusion of osmotic therapies -mannitol and HTS -promote a water shift from intracellular to the extracellular (and thus intravascular) compartments and direct peripheral vasodilation, ultimately leading to CO augmentation [3,32,33]. Moreover, HTS can directly improve myocardial performance through a reduction in myocyte oedema and an increase in myocardial uptake of calcium with restores transmembrane potential [33,34].…”

“…Moreover, HTS can directly improve myocardial performance through a reduction in myocyte oedema and an increase in myocardial uptake of calcium with restores transmembrane potential [33,34]. Current evidence confirms CO enhancement after infusion of either mannitol or HTS [32][33][34]. The different methods used to evaluate systemic haemodynamic changes (pulse contour analysis, pulmonary artery catheter, transoesophageal echocardiography or transthoracic electrical bioimpedance) might be -in part -responsible for the recorded differences.…”

Interactions Within Stroke Systems of Care

“…Until neurosurgical evaluation is obtained, other measures to control intracranial pressure should be considered, such as intubation with modest hyperventilation, furosemide, mannitol, or hypertonic saline. 50,[70][71][72][73][74][75][76][77][78][79][80] The use of telemedicine for stroke care, so-called telestroke, has increased the frequency of "drip-and-ship" treatment, in which patients are diagnosed and treated locally with intravenous tPA and then transferred to a PSC or CSC-type facility for admission and further management. This approach can be used safely, with a high rate of success and a low rate of protocol violations.…”

Management of intracranial hypertension: Recent advances and future directions

“…They include reduction of blood viscosity with subsequent improvement in CBF causing autoregulatory vasoconstriction, endothelial cell shrinkage and improvement in circulation, immune-modulatory role, and decreased production of CSF. [53][54][55] Dosing and concentration of HTS to be used has not been clearly defined. Studies have reported its use in various formats (volume/ dose, ml/kg, mOsm/kg).…”