This Article Extract Full Text (PDF) All Versions of this Article: 39/5/e85    most recent STROKEAHA.108.516435v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Prakash, E.S. Search for Related Content PubMed PubMed Citation Articles by Prakash, E.S. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Hazardous Substances DB D-MANNITOL

(Stroke. 2008;39:e85.)
© 2008 American Heart Association, Inc.

Letters to the Editor

Is the Use of Hypertonic Mannitol Appropriate in the Management of Intracerebral Hemorrhage?

School of Medicine, Asian Institute of Medicine, Science & Technology, Kedah Darul Aman, Malaysia

To the Editor:

This letter comes in the wake of the analysis by Bereczki et al¹ published recently in Stroke. The main rationale for the use of 20% mannitol solutions to reduce intracranial tension rests on the fact that mannitol does not cross the intact blood-brain barrier² in adults. Indeed, a rise in brain mannitol space is evidence of breach of integrity of the blood-brain barrier.³ Thus, in a physiological sense, it is difficult for me to understand how hypertonic mannitol solutions could ever be used in patients known to have intracerebral hemorrhage because it would be associated with the obvious risk of expansion of cerebral hematomas. Yet it is equally possible that the benefits of reducing intracranial pressure (when it is raised) could outweigh this risk. I suspect that the balance between these 2 possibilities may to an extent explain why a randomized controlled study of mannitol in intracerebral hemorrhage⁴ found no evidence of benefit from administering mannitol, and why the confidence intervals of the odds ratio for case fatality at 30 days and 1 year were wide (with the likelihood of harm as well as benefit in some) in the subgroup of 111 patients with intracerebral hemorrhage treated with mannitol.⁵

Acknowledgments

Disclosures

None.

References

1. Bereczki D, Liu M, do Prado GF, Fekete I. Mannitol for acute stroke. Stroke. 2008; 39: 512–513.[Free Full Text]

2. Sweetman SC, ed. Martindale: The Complete Drug Reference. London: Pharmaceutical Press; 2005: 950.

3. Preston JE, A1-Sarraf H, Segal MB. Permeability of the developing blood-brain barrier to 14C-mannitol using the rat in situ brain perfusion technique. Developmental Brain Research. 1995; 87: 69–76.[Medline] [Order article via Infotrieve]

4. Misra UK, Kalita J, Ranjan P, Mandal SK. Mannitol in intracerebral hemorrhage: a randomized controlled study. J Neurol Sci. 2005; 234: 41–45.[CrossRef][Medline] [Order article via Infotrieve]

5. Bereczki D, Mihalka L, Szatmari S, Fekete K, Di Cesar D, Fulesdi B, Csiba L, Fekete I. Mannitol use in acute stroke: case fatality at 30 days and 1 year. Stroke. 2003; 34: 1730–1735.[Abstract/Free Full Text]

This Article Extract Full Text (PDF) All Versions of this Article: 39/5/e85    most recent STROKEAHA.108.516435v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Prakash, E.S. Search for Related Content PubMed PubMed Citation Articles by Prakash, E.S. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Hazardous Substances DB D-MANNITOL