Traumatic brain injury

Is hypertonic saline better than mannitol for traumatic brain injury?

Hypertonic saline is superior to mannitol for the combined effect on intracranial pressure and cerebral perfusion pressure burdens in patients with severe traumatic brain injury.

Mangat HS, Wu X, Gerber LM, et al.

Neurosurgery 2019 (Epub ahead of print).



Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their simultaneous effect on the cerebral perfusion pressure (CPP) and ICP has not been studied rigorously.


To determine the difference in effects of HTS and mannitol on the combined burden of high ICP and low CPP in patients with severe TBI.


We performed a case-control study using prospectively collected data from the New York State TBI-trac® database (Brain Trauma Foundation, New York, New York). Patients who received only 1 hyperosmotic agent, either mannitol or HTS for raised ICP, were included. Patients in the 2 groups were matched (1:1 and 1:2) for factors associated with 2-wk mortality: age, Glasgow Coma Scale score, pupillary reactivity, hypotension, abnormal computed tomography scans, and craniotomy. Primary endpoint was the combined burden of ICPhigh (> 25 mm Hg) and CPPlow (< 60 mm Hg).


There were 25 matched pairs for 1:1 comparison and 24 HTS patients matched to 48 mannitol patients in 1:2 comparisons. Cumulative median osmolar doses in the 2 groups were similar. In patients treated with HTS compared to mannitol, total number of days (0.6 ± 0.8 vs 2.4 ± 2.3 d, P < .01), percentage of days with (8.8 ± 10.6 vs 28.1 ± 26.9%, P < .01), and the total duration of ICPhigh + CPPlow (11.12 ± 14.11 vs 30.56 ± 31.89 h, P = .01) were significantly lower. These results were replicated in the 1:2 match comparisons.


Hypertonic saline bolus therapy appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients.

This paper is cited in the neurochecklist:

Traumatic brain injury (TBI): management

Abstract link

By Rehman T, Ali R, Tawil I, Yonas H – Rehman T, Ali R, Tawil I, Yonas H (2008). “Rapid progression of traumatic bifrontal contusions to transtentorial herniation: A case report”. Cases journal 1 (1): 203. doi:10.1186/1757-1626-1-203. PMID 18831756. PMC 2566562, CC BY 2.0, Link

By Ibrahim Imam

I am a UK Neurologist keen on general neurology, but with an interest in neuromuscular diseases. I maintain the neurology searchable database, I also blog at I share and discuss current issues around clinical neurology. I hope you find my blogs enlightening, practical, and even entertaining.

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