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Effect of mannitol on brain metabolism and tissue oxygenation in severe haemorrhagic stroke
  1. Raimund Helbok1,2,
  2. Pedro Kurtz1,
  3. J Michael Schmidt1,
  4. R Morgan Stuart1,
  5. Luis Fernandez1,
  6. Rishi Malhotra1,
  7. Mary Presciutti1,
  8. Noeleen D Ostapkovich1,
  9. E Sander Connolly1,
  10. Kiwon Lee1,
  11. Neeraj Badjatia1,
  12. Stephan A Mayer1,
  13. Jan Claassen1
  1. 1Division of Neurocritical Care, Department of Neurology, Columbia University Medical Center, Milstein Hospital 8-300 Center, New York, USA
  2. 2Clinical Department of Neurology, Neurological Intensive Care Unit, Medical University Innsbruck, Innsbruck, Austria
  1. Correspondence to Dr Jan Claassen, Division of Critical Care Neurology, Department of Neurology, Columbia University, Milstein Hospital 8 Center, 177 Fort Washington Ave, New York, NY 10032, USA; jc1439{at}


Background The impact of osmotic therapies on brain metabolism has not been extensively studied in humans. The authors examined if mannitol treatment of raised intracranial pressure will result in an improvement in brain metabolism together with the expected drop in intracranial pressure (ICP).

Methods This is a retrospective review of prospectively collected data. Twenty episodes of raised ICP (>20 mm Hg) resistant to standard therapy that required infusions of mannitol were studied in 12 comatose patients with multimodality monitoring including ICP, PbtO2 and microdialysis. The authors compared mean arterial blood pressure, ICP, cerebral perfusion pressure, PbtO2, brain lactate, pyruvate and glucose using cerebral microdialysis, for 3 h preceding and 4 h after hyperosmolar therapy. Time-series data were analysed using a multivariable general linear model utilising generalised estimating equations for model estimation to account for within-subjects and between-subjects variations over time.

Results 20% mannitol solution (1 g/kg) was administered at the discretion of the attending neurointensivist. ICP decreased 30 min (from 27±13 to 19±16 mm Hg, p<0.001) and cerebral perfusion pressure increased 45 min (from 73± 18 to 85±22 mm Hg, p=0.002) after the start of mannitol infusions, whereas mean arterial blood pressure and PbtO2 did not change significantly. The peak lactate–pyruvate ratio was recorded at the time of initiating osmotherapy (44±20) with an 18% decrease over 2 h following mannitol therapy (35±16; p=0.002). Brain glucose remained unaffected.

Conclusions Mannitol effectively reduces ICP and appeared to benefit brain metabolism as measured by the lactate–pyruvate ratio.

  • Intracranial pressure
  • brain oxygen
  • microdialysis
  • mannitol
  • intensive care
  • neurophysiol
  • clinical

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  • Competing interests None.

  • Ethics approval Ethics approval was provided by the Internal Review Board, Columbia University.

  • Provenance and peer review Not commissioned; externally peer reviewed.