The Use of Mannitol in

Patients with Increased

Intracranial Pressure

B. Priyanto
 Outline
1. Case
2. Intracranial
Hypertension
3. Mannitol and
hyperosmolar therapy
4. Recommendation
5. Controversies
6. Conclusions
1. Case
Male, 42 yrs old

Complaint of sudden
decreased of consciousness
after breakfast, projectile
vomiting and right side
weakness. History of
hypertension without any
medication regularly.

This patient referred from

remote hospital about 8 hours
travel of distance
 1. Case
Physical Examination (previous hospital)

Vital Sign : BP 200/110, HR 64, RR 25 and T 36,7 C

GCS E2V1M3, pupils isokor, positive light reaction on both pupils directly and
indirectly, negative sign of neck stiffness, right side lateralization
 1. Case

Diagnose : Hipertensive hemorhagic CVA

Previous Therapy :
Crystalloid infusion, Nasal Canule Oxygenation, brain protectors,
antivomitting.
 2. Intracranial Hypertension
Intracranial pressure (ICP) is the pressure inside the skull and thus in the brain tissue
and cerebrospinal fluid (CSF) (wikipedia)
Normal Values of Intracranial Pressure :

Adults and Older Children : 10-15 mm Hg

Young Children : 3 – 7 mm Hg
Infants : 1,5-6 mm Hg

ICP > 20 to 25 mm Hg  require treatment in most circumstances.

Sustained ICP > 40 mm Hg  severe, life-threatening intracranial hypertension
Indian J Pediatr (2010) 77 : 1409-1416
Intracranial Hypertension (ICH) : The elevation of intracranial pressure (ICP)
due to the disturbance of regulatory intracranial pressure mechanisms
2. Intracranial Hypertension
Monroe – Kellie Doctrine
Volume Intracranial (constant)
Vic = Vblood + VCSF + Vparenchyma
 2. Intracranial Hypertension
Cerebral Pressure Dynamics :
CPP = MAP – ICP
Where MAP = 1/3 SBP + 2/3 DBP
adults CPP > 70 mm Hg; children CPP > 50–60 mm Hg; infants/toddlers CPP > 40– 50 mm Hg

Vasodilatory Cascade 
How can we stop the
ischemia
2. Intracranial Hypertension
Vasodilatory Cascade : Potential Therapeutic
 2. Intracranial Hypertension

7 Steps
Levels of
Therapy

Textbook of Neurological surgery p2816

 2. Intracranial Hypertension
Sign and Symptoms :
headache, vomiting without nausea, ocular palsies, altered level of
consciousness, back pain, double vision, weakness, numbness

Papiledema, Pupillary dilation, abduscens palsies, cushing’s triad,

abnormally respiratory pattern, motoric disturbances
3. Mannitol and Hyper Osmolar
Therapy
The discovery of mannitol is attributed to Joseph Louis Proust in
1806

Mannitol is a type of sugar which is also used as a medication

wikipedia
 3. Mannitol and Hyper Osmolar
Therapy
Mannitol is contraindicated in people with
anuria, congestive heart failure

Side effects :
Common side effects electrolyte problems and
dehydration.
Other serious side effects : worsening heart failure
and kidney problems.
Safety in pregnancy is unclear.
wikipedia
 3. Mannitol and Hyper Osmolar
Therapy
Mannitol use in Intracranial Hypertension is advocated in two
circumstances :
1. A single administration can have short term beneficial effects, during
which further diagnostic procedures and interventions can be accomplished
2. Prolonged therapy for raised ICP
 3. Mannitol and Hyper Osmolar
Therapy
Mannitol possible effects in the brain :
1. Rheological effects, immediate plasma expanding, reduces
hematocrit, increases deformability of erythrocytes, reduces blood viscosity,
increases CBF and increases cerebral oxygen delivery  Reduces ICP within
few minutes of its administration and most marked in patients with low
CPP (<70)
2. Osmotic effect, this effect delayed for 15-30 min and persists for a variable
period of 90 min to 6/> hour

https://www.braintrauma.org/uploads/11/14/Guidel
ines_Management_2007w_bookmarks_2.pdf
3. Mannitol and Hyper Osmolar
Therapy

Mannitol potentiates Oxygen delivery and decreased viscosity

 3. Mannitol and Hyper Osmolar
Therapy
Hypertonic Saline (HS):
1. Ideally, intervention of ICP control should effectively  ICP while
preserve or  CPP. A bear risk of ICP control (mannitol and
barbiturat) further CPP
2. HS Osmotic effect  osmotic mobilization of water across the
intact blood-brain barrier
3. HS on microcirculation :
• dehydrates endothelial cells and erythrocytes which increases the
diameter of the vessels and deformability of erythrocytes,
• plasma volume expansion with improved blood flow,
• reduces leukocyte adhesion in the traumatized brain.
Neurologic Clinics, Volume 26, Issue 2, Pages 521-541
 3. Mannitol and Hyper Osmolar
Therapy
Hypertonic Saline (HS) has clear advantage over
mannitol in hypovolemic and hypotensive patients,

Hypertonic Saline (HS) adverse effects :

1. Hematologic and electrolytes abnormalities (bleeding
secondary to decreased platelet aggregation and prolonged
coagulation times, hypokalemia and hyperchloremia)
2. Central pontine myelinolysis
3. Inducing or aggravating pulmonary edema
Neurologic Clinics, Volume 26, Issue 2, Pages 521-541
3. Mannitol and Hyper Osmolar
Therapy
GCS E2V2M5, dilated left pupil
and right hemiparese

Patient were intubated and

ventilated

surgically treated by
decompressive craniotomy
4. Recommendation

https://www.braintrauma.org/up
loads/11/14/Guidelines_Manage
ment_2007w_bookmarks_2.pdf
 4. Recommendation

https://www.braintrauma.org/uploads/11/14/Guidelines_Management_2007w_bookmarks_2.pdf
 4. Recommendation
1. Mannitol dose : 0,25 g/kg – 1 g/kg BW. An initial dose of 1 g/kgBW

when long term therapy : 0,25 -0,5 g/kgBW every 2-6 hrs.

2. Hypertonic Saline given in concentrations ranging from 3% - 23,4

%. Effective doses range between 0,1-1 mL/kgBW per hour.

Neurologic Clinics, Volume 26, Issue 2, Pages 521-541

 5. Controversies

1. Mannitol prolonged therapy

2. Mannitol in hemorrhagic patients

3. Mannitol vs Hypertonic Saline

 6. Conclusion
1. The ideally treatment of intracranial Hypertension should
effectively  ICP while preserve or  CPP
2. There are 7 steps level therapy for intracranial hypertension
starts from primary resuscitation until barbiturate therapy.
3. Mannitol and hyper osmolar therapy could be administered
in patients with intracranial hypertension