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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 1  |  Page : 212-213

Sugar or Salt? Survey on the Use of Mannitol or Hypertonic Saline for Cerebral Edema Due to Traumatic Brain Injury

1 Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical sciences, Lucknow, Uttar Pradesh, India
2 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru, Karnataka, India

Date of Submission17-Sep-2018
Date of Decision17-Sep-2018
Date of Acceptance22-Jul-2019
Date of Web Publication24-Feb-2021

Correspondence Address:
Dhaval Shukla
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru - 560 029, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.310111

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How to cite this article:
Deora H, Shukla D. Sugar or Salt? Survey on the Use of Mannitol or Hypertonic Saline for Cerebral Edema Due to Traumatic Brain Injury. Neurol India 2021;69:212-3

How to cite this URL:
Deora H, Shukla D. Sugar or Salt? Survey on the Use of Mannitol or Hypertonic Saline for Cerebral Edema Due to Traumatic Brain Injury. Neurol India [serial online] 2021 [cited 2021 Apr 10];69:212-3. Available from:


Hyperosmolar therapy is a cornerstone in the medical management of cerebral edema and raised intracranial pressure (ICP). Mannitol has been considered as a gold standard hyperosmolar therapy for the medical management of intracranial hypertension [ICH]. Recently the use of hypertonic saline (HTS) has increased in practice for treatment of ICH.

In a recently concluded Continuing Medical Education (CME) on Neurotrauma in Udaipur in July 2018, conducted under the aegis of Neurological society of India (NSI) a survey on the role of hyperosmolar therapy for cerebral edema in trauma yielded some interesting results. The participants of this CME were young neurosurgeons with interest in neurotrauma. This survey was sent to all participants attending the CME in the form of a using Google forms. Prior to the survey administration, all participants of CME received an e-mail inviting them to complete the survey. No incentive was given. A total of 23 out of the 57 (40.3%) neurosurgeons responded to the survey. The survey consisted of 6 questions using either nominal or ordinal data measurement options designed to ascertain the use of type of hyperosmolar therapy and the barriers in the use of hypertonic saline (HTS).

Most of the respondents (95.4%) were engaged in group practice either in an academic institution (65.2%) or in a private hospital (30.2%) [Figure 1]. A large majority of participants (60.9%) responded that they use mannitol frequently in the management of severe TBI in adults. However, only 47.8% used HTS. In pediatric population only 4.4% of the participants used HTS exclusively while 30.4% of the responders preferred only mannitol. Among the dual users, HTS is preferred by 34.8% and continuous intravenous administration was preferred by 69.6% over intermittent bolus dosage. The results of the survey lead us to believe that HTS use has still not gained popularity in management of TBI in India. When asked on the major obstacle to the use of HTS in severe TBI the most cited one was its comparable treatment efficacy to mannitol (39.1%) followed by its non-availability (8.7%). The 47.8% users of HTS previously cited reported no obstacle in its use.
Figure 1: Pie Charts representing the questions asked, options available and answers given along with percentage of each

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Mannitol is a sugar alcohol that decreases water and sodium reabsorption in the renal tubule. It lowers ICP through two distinct effects in the brain. The first, rheological effect, reduces blood viscosity and promotes plasma expansion and cerebral oxygen delivery. In response, cerebral vasoconstriction occurs due to autoregulation, and cerebral blood volume is decreased. The second effect occurs through creation of an osmotic gradient across the blood-brain barrier, leading to the movement of water from the parenchyma to the intravascular space. Brain tissue volume is decreased and, therefore, ICP is lowered. Mannitol is recommended as the first-line osmotic agent for the treatment of ICH attributable to traumatic brain injury (TBI).

Recently, many adverse effects of mannitol have been identified, such as acute renal failure, rebound ICP elevation, and hypovolemia. As an alternative therapeutic approach, HTS has been used to treat patients with elevated ICP. The mechanisms of action of HTS are many, with the most common involving the creation of an osmotic shift of fluid from the intracellular space to the interstitial and intravascular space. Further mechanisms of HTS include direct vasodilation, increased cardiac output, and potential neurochemical and immune-modulating effects. The osmolality of 3% HTS is similar to that of 20% mannitol. When given as intermittent bolus the dose of 20% mannitol and 3% saline is same. When given as continuous infusion the dose of 3% HTS ranges from 0.1 ml/kg to 1 ml/kg titrated to ICP values or serum sodium values. Mannitol needs to be stopped when serum osmolality exceeds 320 mOsm/l or osmolality gap >20 mOsm/l. HTS needs to be stopped when serum sodium exceeds 155 mEq/l. The results of recent meta-analysis do not lead a specific recommendation to select HTS or mannitol as a first-line for the patients with elevated ICP due to TBI.[1] However, for the refractory ICH, HTS seems to be preferred. HTS is also preferred in hypovolemic states.

From our short survey, it is clear that mannitol is still preferred over HTS in TBI. Similar surveys among neurosurgeons, critical and emergency care physicians and even anesthesiologists yielded similar results to the attitude over the use of HTS.[2],[3],[4] The perceived barriers in the use of HTS are the absence of clinical guidelines approving their use, the availability of a comparable treatment (mannitol) and that hypertonic saline solutions use was not evidence-based. Despite an ever-growing body of evidence showing promising results with the use of hypertonic saline to manage increased intracranial pressure in adult patients with severe traumatic brain injury there have been no recommendations regarding the superiority of one over the other. Our survery highlights the cross-roads we now stand at Sugar or salt?

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There are no conflicts of interest.

  References Top

Gu J, Huang H, Huang Y, Sun H, Xu H. Hypertonic saline or mannitol for treating elevated intracranial pressure in traumatic brain injury: A meta-analysis of randomized controlled trials. Neurosurg Rev 2019;42:499-509.  Back to cited text no. 1
Jacka ML, Zygun D. Survey of management of severe head injury in Canada. Can J Neurol 2007;34:307-12.  Back to cited text no. 2
Wenham TN, Hormis AP, Andrzejowski JC. Hypertonic saline after traumatic brain injury in UK neuro-critical care practice. Anaesthesia 2008;63:558-9.  Back to cited text no. 3
Berger Pelletier E, Émond M, Lauzier F, Savard M, Turgeon AF. Hyperosmolar therapy in severe traumatic brain injury: A survey of emergency physicians from a large Canadian province. PLoS One 2014;9:e95778.  Back to cited text no. 4


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