Effects of hypertonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke.
OBJECTIVE
The purpose of this study was to prospectively evaluate a protocol with hypertonic saline hydroxyethyl starch (HS-HES) and mannitol in stroke patients with increased intracranial pressure (ICP).


METHODS
We studied 30 episodes of ICP crisis in 9 patients. ICP crisis was defined as (1) a rise of ICP of more than 25 mm Hg (n = 22), or (2) pupillary abnormality (n=3), or (3) a combination of both (n=5). Baseline treatment was performed according to a standardized protocol. For initial treatment, the patients were randomly assigned to either infusion of 100 mL HS-HES or 40 g mannitol over 15 minutes. For repeated treatments the 2 substances were alternated. ICP, blood pressure, and cerebral perfusion pressure (CPP) were monitored over 4 hours. Blood gases, hematocrit, blood osmolarity, and sodium were measured before and 15 and 60 minutes after the start of infusion. Treatment was regarded as effective if ICP decreased >10% below baseline value or if the pupillary reaction had normalized.


RESULTS
Treatment was effective in all 16 HS-HES-treated and in 10 of 14 mannitol-treated episodes. ICP decreased from baseline values in both groups, P < 0.01. The maximum ICP decrease was 11.4 mm Hg (after 25 minutes) in the HS-HES-treated group and 6.4 mm Hg (after 45 minutes) in the mannitol-treated group. There was no constant effect on CPP in the HS-HES-treated group, whereas CPP rose significantly in the mannitol-treated group. Blood osmolarity rose by 6.2 mmol/L in the mannitol-treated group and by 10.5 mmol/L in the HS-HES-treated group; sodium fell by 3.2 mmol/L in the mannitol and rose by 4.1 mmol/L in the HS-HES-treated group.


CONCLUSIONS
Infusion of 40 g mannitol and 100 mL HS-HES decreases increased ICP after stroke. The maximum effect occurs after the end of infusion and is visible over 4 hours. HS-HES seems to lower ICP more effectively but does not increase CPP as much as does mannitol.
Department of Neurology, University of Heidelberg, Germany. Stefan_Schwarz@ukl.uni-heidelberg.de
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Schwarz
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Schwab
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Bertram
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Aschoff
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Hacke
D000328:Adult; D000368:Aged; D001794:Blood Pressure; D001929:Brain Edema / Q000150:complications / Q000188:drug therapy; D002561:Cerebrovascular Disorders / Q000150:complications / Q000188:drug therapy* / Q000517:prevention & control; D004234:Diuretics, Osmotic / Q000008:administration & dosage*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000008:administration & dosage*; D019586:Intracranial Hypertension / Q000188:drug therapy* / Q000209:etiology; D008297:Male; D008353:Mannitol / Q000008:administration & dosage*; D008875:Middle Aged; D009994:Osmolar Concentration; D010952:Plasma Substitutes / Q000008:administration & dosage*; D011446:Prospective Studies; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage*; D016896:Treatment Outcome
D004234:Diuretics, Osmotic; D006895:Hydroxyethyl Starch Derivatives; D010952:Plasma Substitutes; D012462:Saline Solution, Hypertonic; D008353:Mannitol