title: Reversal of transtentorial herniation with hypertonic saline.
abstract: OBJECTIVE
  To evaluate the role of 23.4% saline in the management of transtentorial herniation (TTH) in patients with supratentorial lesions.
  
  
  METHODS
  Consecutive patients with clinically defined TTH treated with 23.4% saline (30 to 60 mL) were included in a retrospective cohort. Factors associated with successful reversal of TTH were determined.
  
  
  RESULTS
  Seventy-six TTH events occurred in 68 patients admitted with intracerebral hemorrhage (n = 29), subarachnoid hemorrhage (n = 16), stroke (n = 8), brain tumor (n = 8), subdural hematoma (n = 5), epidural hematoma (n = 1), and meningitis (n = 1). In addition to 23.4% saline, TTH management included hyperventilation (70% of events), mannitol (57%), propofol (62%), pentobarbital (15%), ventriculostomy drainage (27%), and decompressive hemicraniectomy (18%). Reversal of TTH occurred in 57/76 events (75%). Intracranial pressure decreased from 23 +/- 16 mm Hg at the time of TTH to 14 +/- 10 mm Hg at 1 hour (p = 0.002), and 11 +/- 12 mm Hg at 24 hours (p = 0.001) among 22 patients with intracranial pressure monitors. Reversal of TTH was predicted by a >/=5 mmol/L rise in serum sodium concentration (p = 0.001) or an absolute serum sodium of >/=145 mmol/L (p = 0.007) 1 hour after 23.4% saline. Adverse effects included transient hypotension in 13 events (17%); no evidence of central pontine myelinolysis was detected on post-herniation MRI (n = 18). Twenty-two patients (32%) survived to discharge, with severe disability in 17 and mild to moderate disability in 5.
  
  
  CONCLUSIONS
  Treatment with 23.4% saline was associated with rapid reversal of transtentorial herniation (TTH) and reduced intracranial pressure, and had few adverse effects. Outcomes of TTH were poor, but medical reversal may extend the window for adjunctive treatments.
authors.affiliation: Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, 600 N Wolfe St., Meyer 8-140, Baltimore, MD 21287, USA.
authors.forename: M A
authors.initials: MA
authors.lastname: Koenig
authors.forename: M
authors.initials: M
authors.lastname: Bryan
authors.forename: J L
authors.initials: JL
authors.lastname: Lewin
authors.forename: M A
authors.initials: MA
authors.lastname: Mirski
authors.forename: R G
authors.initials: RG
authors.lastname: Geocadin
authors.forename: R D
authors.initials: RD
authors.lastname: Stevens
mesh_terms: D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000187:drug effects; D001921:Brain / Q000187:drug effects* / Q000503:physiopathology; D001929:Brain Edema / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D001932:Brain Neoplasms / Q000150:complications; D002543:Cerebral Hemorrhage / Q000150:complications; D015331:Cohort Studies; D004234:Diuretics, Osmotic / Q000627:therapeutic use; D004334:Drug Administration Schedule; D005260:Female; D006547:Hernia / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D019586:Intracranial Hypertension / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D007427:Intracranial Pressure / Q000187:drug effects; D008297:Male; D008353:Mannitol / Q000009:adverse effects; D008875:Middle Aged; D012189:Retrospective Studies; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use*; D012964:Sodium / Q000097:blood; D015996:Survival Rate; D016896:Treatment Outcome; D014882:Water-Electrolyte Balance / Q000187:drug effects
chemical_list: D004234:Diuretics, Osmotic; D012462:Saline Solution, Hypertonic; D008353:Mannitol; D012964:Sodium