Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses of mannitol: a randomized trial.
OBJECTIVE
To evaluate clinical outcomes and postoperative physiological findings for comatose patients with acute subdural hematomas who received preoperative high-dose mannitol (HDM) versus conventional-dose mannitol treatment.


METHODS
One hundred seventy-eight adult patients with non-missile, traumatic, acute, subdural hematomas were prospectively and randomly assigned to receive emergency, preoperative, intravenous HDM treatment (91 patients), compared with a control group treated with a lower preoperative mannitol dose (87 patients).


RESULTS
Preoperative improvement of abnormal pupillary widening was significantly more frequent in the study group than in the control group of patients (P < 0.0001). Preoperative HDM treatment was also associated with significantly better clinical outcomes at 6-month follow-up evaluations (P < 0.01). Postoperative physiological findings revealed statistically significant between-group differences, with higher intracranial pressure and lower cerebral extraction of oxygen (relative cerebral hyperperfusion) in the control group, compared with the HDM group. Postoperative global brain ischemia (abnormally low arteriojugular lactate difference values) was rare and was detected in 2.2 and 3.4% of the patients in the study and control groups, respectively.


CONCLUSIONS
Emergency preoperative HDM administration was associated with improved clinical outcomes for patients with acute subdural hematomas. Preoperative improvement of abnormal pupillary widening and better postoperative control of intracranial hypertension and associated relative cerebral hyperperfusion seemed to be relevant factors associated with improved outcomes.
Cruz
J
J
The Comprehensive International Center for Neuroemergencies and Federal University of São Paulo, São Paulo SP 04093-970, Brazil.
Minoja
G
G
Okuchi
K
K
D000328:Adult; D004305:Dose-Response Relationship, Drug; D004630:Emergencies; D005260:Female; D020199:Hematoma, Subdural, Acute / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D007427:Intracranial Pressure / Q000187:drug effects; D019344:Lactic Acid / Q000097:blood; D008297:Male; D008353:Mannitol / Q000008:administration & dosage*; D009460:Neurologic Examination; D010101:Oxygen Consumption / Q000187:drug effects; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology; D011292:Premedication; D012025:Reflex, Pupillary / Q000187:drug effects; D016896:Treatment Outcome
D019344:Lactic Acid; D008353:Mannitol