Comparison of mannitol and hypertonic saline in the treatment of severe brain injuries

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The purpose of this study was to compare the effects of mannitol and hypertonic saline in doses of similar osmotic burden for the treatment of intracranial hypertension in patients with severe traumatic brain injury.


The authors used an alternating treatment protocol to compare the effect of hypertonic saline with that of mannitol given for episodes of increased intracranial pressure in patients treated for severe head injury at their hospital during 2006–2008. Standard guidelines for the management of severe traumatic brain injury were followed. Elevated intracranial pressure (ICP) was treated either with mannitol or hypertonic saline. Doses of similar osmotic burden (mannitol 20%, 2 ml/kg, infused over 20 minutes, or saline 15%, 0.42 ml/kg, administered as a bolus via a central venous catheter) were given alternately to the individual patient with severe brain injury during episodes of increased pressure. The dependent variables were the extent and duration of reduction of increased ICP. The choice of agent for treatment of the initial hypertensive event was determined on a randomized basis; treatment was alternated for every subsequent event in each individual patient. Reduction of ICP and duration of action were recorded after each event. Results obtained after mannitol administration were statistically compared with those obtained after hypertonic saline administration.


Data pertaining to 199 hypertensive events in 29 patients were collected. The mean decrease in ICP obtained with mannitol was 7.96 mm Hg and that obtained with hypertonic saline was 8.43 mm Hg (p = 0.586, equal variances assumed). The mean duration of effect was 3 hours 33 minutes for mannitol and 4 hours 17 minutes for hypertonic saline (p = 0.40, equal variances assumed).


No difference between the 2 medications could be found with respect to the extent of reduction of ICP or duration of action.

Abbreviations used in this paper: GCS = Glasgow Coma Scale; ICP = intracranial pressure; TBI = traumatic brain injury.

Article Information

Address correspondence to: Nikolaos Sakellaridis, M.D., Karaiskaki 23, 15451, Neo Psychiko, Attica, Greece. email:

Please include this information when citing this paper: published online November 19, 2010; DOI: 10.3171/2010.5.JNS091685.

© AANS, except where prohibited by US copyright law.



  • 1

    Bullock RMChestnut RMClifton GLGhajar JMarion DWNarayan RK: Use of mannitol. J Neurotrauma 17:5215252000

  • 2

    Doyle JADavis DPHoyt DB: The use of hypertonic saline in the treatment of traumatic brain injury. J Trauma 50:3673832001

  • 3

    Harutjunyan LHolz CRieger AMenzel MGrond SSoukup J: Efficiency of 7.2% hypertonic saline hydroxyethyl starch 200/0.5 versus mannitol 15% in the treatment of increased intracranial pressure in neurosurgical patients—a randomized clinical trial [ISRCTN62699180]. Crit Care 9:R530R5402005

    • Search Google Scholar
    • Export Citation
  • 4

    Lehr R: Sixteen S-squared over D-squared: a relation for crude sample size estimates. Stat Med 11:109911021992

  • 5

    Ogden ATMayer SAConnolly ES Jr: Hyperosmolar agents in neurosurgical practice: the evolving role of hypertonic saline. Neurosurgery 57:2072152005

    • Search Google Scholar
    • Export Citation
  • 6

    Soustiel JFVlodavsky EZaaroor M: Relative effects of mannitol and hypertonic saline on calpain activity, apoptosis and polymorphonuclear infiltration in traumatic focal brain injury. Brain Res 1101:1361442006

    • Search Google Scholar
    • Export Citation
  • 7

    Thomas L: Retrospective power analysis. Conserv Biol 11:2762801997

  • 8

    Vialet RAlbanèse JThomachot LAntonini FBourgouin AAlliez B: Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Crit Care Med 31:168316872003

    • Search Google Scholar
    • Export Citation
  • 9

    Wade CEGrady JJKramer GCYounes RNGehlsen KHolcroft JW: Individual patient cohort analysis of the efficacy of hypertonic saline/dextran in patients with traumatic brain injury and hypotension. J Trauma 42:5 SupplS61S651997

    • Search Google Scholar
    • Export Citation
  • 10

    Wakai ARoberts ISchierhout G: Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev 1CD0010492007

  • 11

    Yilmaz NDulger HKiymaz NYilmaz CGudu BODemir I: Activity of mannitol and hypertonic saline therapy on the oxidant and antioxidant system during the acute term after traumatic brain injury in the rats. Brain Res 1164:1321352007

    • Search Google Scholar
    • Export Citation

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