Current Treatment Options in Neurology

, Volume 1, Issue 3, pp 179–187 | Cite as

Cerebral edema: Hypertonic saline solutions

  • Anish Bhardwaj
  • John A. Ulatowski

Opinion statement

Our experience, and that of others, suggests that hypertonic saline solution therapy reduces intracranial pressure and lateral displacement of the brain in patients with cerebral edema. This therapy appears most promising in patients who have head trauma or postoperative cerebral edema. Studies comparing hypertonic saline therapy with conventional therapies are limited. Additional randomized studies are needed to determine its safety and optimum duration of benefit and to determine the lesions most likely to be improved. To date, the cost effectiveness of hypertonic saline therapy is unknown. Caution is advised regarding its use until the results of more definitive trials investigating its efficacy and safety are known.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Readings

  1. 1.
    Bingaman WE, Frank JI: Malignant cerebral edema and intracranial hypertension. Neurol Clin 1995, 13:479–509.PubMedGoogle Scholar
  2. 2.
    Zornow MH: Hypertonic saline as a safe and efficacious treatment of intracranial hypertension. J Neurosurg Anesthesiol 1996, 8:175–177. This article reviews the history, pathophysiologic basis, experimental evidence, and clinical study results of the use of hypertonic saline solutions for the treatment of intracranial hypertension.PubMedGoogle Scholar
  3. 3.
    Weed LH, McKibben PS: Experimental alteration of brain bulk. Am J Physiol 1919, 48:531–555.Google Scholar
  4. 4.
    Todd MM, Tommasino C, Moore S: Cerebral effects of isovolemic hemodilution with a hypertonic saline solution. J Neurosurg 1985, 63:944–948.PubMedGoogle Scholar
  5. 5.
    Ducey JP, Mozingo DW, Lamiell JM, et al.: A comparison of the cerebral and cardiovascular effects of complete resuscitation with isotonic and hypertonic saline, hetastarch, and whole blood following hemorrhage. J Trauma 1989, 29:1510–1518.PubMedGoogle Scholar
  6. 6.
    Schmoker J, Zhuang J, Schackford S: Hypertonic fluid resuscitation improves cerebral oxygen delivery and reduces intracranial pressure after hemorrhagic shock. J Trauma 1991, 31:1607–1613.PubMedGoogle Scholar
  7. 7.
    Prough DS, Whitley J, Taylor CL, et al.: Regional cerebral blood flow following resuscitation from hemorrhagic shock with hypertonic saline. Anesthesiology 1991, 75:319–327.PubMedCrossRefGoogle Scholar
  8. 8.
    Denchev D, Schnitzer M, Mirski M, et al.: Treatment of elevated intracranial pressure in an experimental awake model of focal cerebral injury: comparison between mannitol and hypertonic saline. In Intracranial Pressure IX. Edited by Ngai H, Kamiya K, Ishii S. Tokyo: Springer-Verlag; 1994:658–659.Google Scholar
  9. 9.
    Miller JD, Leech P: Effects of mannitol and steroid therapy on intracranial volume-pressure relationships in patients. J Neurosurg 1975, 42:274–281.PubMedGoogle Scholar
  10. 10.
    Cottrell JE, Robustelli A, Post K, et al.: Furosemide- and mannitol-induced changes in intracranial pressure and serum osmolality and electrolytes. Anesthesiology 1977, 47:28–30.PubMedCrossRefGoogle Scholar
  11. 11.
    James HE, Langfitt TW, Kumar VS, et al.: Treament of intracranial hypertension: analysis of 105 consecutive, continous recordings of intracranial pressure. Acta Neurochirsurgica 1977, 36:189–200.CrossRefGoogle Scholar
  12. 12.
    Marshall LF, Smith RW, Rauscher LA, et al.: Mannitol dose requirements in brain-injured patients. J Neurosurg 1978, 48:169–172.PubMedGoogle Scholar
  13. 13.
    Muizelaar JP, Lutz HA, Becker DP: Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head-injured patients. J Neurosurg 1984, 61:700–706.PubMedGoogle Scholar
  14. 14.
    Mendelow AD, Teasedale GM, Russell T, et al.: Effect of mannitol on cerebral blood flow and cerebral perfusion pressure in human head injury. J Neurosurg 1985, 63:43–48.PubMedGoogle Scholar
  15. 15.
    Smith HP, Kelly DL, McWhorter JM, et al.: Comparison of mannitol regimens in patients with severe head injury undergoing intracranial monitoring. J Neurosurg 1986, 65:820–824.PubMedGoogle Scholar
  16. 16.
    Worthley LI, Cooper DJ, Jones N: Treatment of resistant intracranial hypertension with hypertonic saline: report of two cases. J Neurosurg 1988, 68:478–481.PubMedGoogle Scholar
  17. 17.
    Fisher B, Thomas D, Peterson B: Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol 1992, 4:4–10.PubMedCrossRefGoogle Scholar
  18. 18.
    Yu YL, Kumana CR, Lauder IJ, et al.: Treatment of acute cerebral hemorrhage with intravenous glycerol: a double-blind, placebo-controlled, randomized trial. Stroke 1992, 23:967–971.PubMedGoogle Scholar
  19. 19.
    Gemma M, Cozzi S, Poccoli C, et al.: Hypertonic saline fluid therapy following brain stem trauma. J Neurosurg Anesthesiol 1996, 8:137–141.PubMedGoogle Scholar
  20. 20.
    Gemma M, Cozzi S, Tommasino C, et al.: 7.5% hypertonic saline versus 20% mannitol during elective neurosurgical supratentorial procedures. J Neurosurg Anesthesiol 1997, 9:329–334.PubMedGoogle Scholar
  21. 21.
    Qureshi AI, Suarez JI, Bhardwaj A, et al.: Use of hypertonic (3%) saline/acetate infusion in the treatment of cerebral edema: effect on intracranial pressure and lateral displacement of the brain. Crit Care Med 1998, 26:440–446.PubMedCrossRefGoogle Scholar
  22. 22.
    Suarez JI, Qureshi AI, Bhardwaj A, et al.: Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med 1998, 26:1118–1122. This article presents the results of a case series of patients with intracranial hypertension refractory to treatment by conventional therapies. Intravenous boluses (30 mL) of 23.4% saline reduced intracranial pressure and augmented cerebral perfusion pressure for several hours in these patients.PubMedCrossRefGoogle Scholar
  23. 23.
    Shackford SR, Bourguignon PR, Wald SL, et al.: Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial. J Trauma 1998, 44:50–58.PubMedGoogle Scholar
  24. 24.
    Simma B, Burger R, Falk M, et al.: A prospective, randomized, and controlled study of fluid management in children with severe head injury: lactated Ringer’s solution versus hypertonic saline. Crit Care Med 1998, 26:1265–1270. This article describes a prospective, randomized, controlled trial of lactated Ringer’s or hypertonic saline therapy after severe traumatic brain injury in children. Patients administered hypertonic saline had lower levels of intracranial pressure and cerebral perfusion pressure, fewer complications, and shorter intensive care unit stays.PubMedCrossRefGoogle Scholar
  25. 25.
    Schwarz S, Schwab S, Bertram M, et al.: Effect of hypertonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke. Stroke 1998, 29:1550–1555.PubMedGoogle Scholar
  26. 26.
    Weinstabl C, Mayer N, Germann P, et al.: Hypertonic, hyperoncotic hydroxyethyl starch decreases intracranial pressure following neurotrauma [abstract]. Anesthesiology 1992, 75:A201.CrossRefGoogle Scholar
  27. 27.
    Manninen PH, Lam AM, Gelb AW, et al.: The effect of high dose mannitol on serum and urine electrolytes and osmolality in neurosurgical patients. Can J Anaesth 1987, 34:442–446.PubMedCrossRefGoogle Scholar
  28. 28.
    Rudehill A, Gordon E, Ohman G, et al.: Pharmacokinetics and effects of mannitol on hemodynamics, blood and cerebrospinal fluid electrolytes, and osmolality during intracranial surgery. J Neurosurg Anesthesiol 1993, 5:4–12.PubMedGoogle Scholar
  29. 29.
    Schell RM, Applegate RL II, Cole DJ: Salt, starch, and water on the brain. J Neurosurg Anesthesiol 1996, 8:178–182. This article reviews the pathophysiologic and therapeutic bases for the use of hyperosmotic fluids in the treatment of brain edema of diverse causes.PubMedGoogle Scholar

Copyright information

© Current Science Inc 1999

Authors and Affiliations

  • Anish Bhardwaj
    • 1
  • John A. Ulatowski
    • 1
  1. 1.Neuroscience Critical Care Division, Johns Hopkins University School of MedicineMeyer 8-140, Johns Hopkins HospitalBaltimoreUSA

Personalised recommendations