Stroke. 2008;39:512-513
Published online before print January 3, 2008,
doi: 10.1161/STROKEAHA.107.496778
(Stroke. 2008;39:512.)
© 2008 American Heart Association, Inc.
Mannitol for Acute Stroke
Dániel Bereczki, MD, PhD, DSc;
Ming Liu, MD;
Gilmar Fernandes do Prado, MD, PhD
István Fekete, MD, PhD
From the Department of Neurology (D.B.), Semmelweis University, Budapest, Hungary; the Department of Neurology (D.B., I.F.), Health Science and Medical Center, University of Debrecen, Hungary; the Department of Neurology (M.L.), West China Hospital, Sichuan University, China; and the Department of Internal Medicine (G.F.d.P.), Federal University of Sao Paulo, Brazil.
Correspondence to Dr Daniel Bereczki, Department of Neurology, Semmelweis University, Balassa U. 6, Budapest, Hungary, H-1083. E-mail bereczki{at}neur.sote.hu
Graeme J. Hankey MD, FRCP Section Editor:
Key Words: acute stroke edema, brain systematic review treatment
 |
Introduction
|
|---|
Mannitol is an osmotic agent and a free radical scavenger and
thus might decrease edema and tissue damage in stroke, and has
been given a Class 2a recommendation (ie, probably indicated
to decrease brain edema after large cerebral infarctions) for
use in acute stroke in recent guidelines.
1
 |
Objectives
|
|---|
To test whether treatment with mannitol reduces short and long-term
case fatality and dependency after acute ischemic stroke or
intracerebral hemorrhage (ICH).
 |
Search Strategy
|
|---|
We searched the Cochrane Stroke Group Trials Register, the Chinese
Stroke Trials Register, the China Biological Medicine Database,
MEDLINE (1966 to 2006), and the Latin-American database LILACS
(1982 to December 2006). In addition we searched the database
of Masters and PhD degree theses at Sao Paulo University and
abstracts of medical congresses on neurology and neurosurgery
from 1965 to 2006 in Brazil. We searched reference lists and
contacted authors of published trials. Last searches were performed
between September 2006 and February 2007.
 |
Selection Criteria
|
|---|
Truly randomized unconfounded clinical trials comparing the
effect of mannitol with placebo or open control in patients
with acute ischemic stroke or nontraumatic intracerebral hemorrhage
were eligible for inclusion.
 |
Data Collection and Analysis
|
|---|
Two reviewers independently selected the trials for inclusion,
extracted, and analyzed the data. Included trials were tabulated
for methodological quality. Data synthesis and analysis was
performed using RevMan version 4.3.1.
 |
Main Results
|
|---|
Three trials fulfilled the inclusion criteria. The number of
included patients was small (21, 77, and 128 patients). One
trial with 77 subjects randomized patients with presumed ischemic
stroke without CT verification, and the other 2 trials included
patients with CT verified ICH. Data on the primary outcome measure
(ie, death and dependency) were not available in any of the
trials. Death and disability could be calculated in the larger
trial on ICH, without differences between the mannitol and the
control groups (Peto OR: 1.28, 95% CI: 0.64 to 2.56). Of the
secondary outcome measures, case fatality was not reported in
the single trial on ischemic stroke and data were not available
from the investigators. Case fatality did not differ between
the mannitol and the control groups in the 2 small trials on
ICH (Peto OR: 1.03, 95% CI: 0.47 to 2.25;
Figure). Clinical
improvement was not more frequent after mannitol treatment in
any of the trials. Adverse events were either not found or not
reported in the trials. Based on these 3 small trials neither
beneficial nor harmful effects of mannitol could be proved.
Although no statistically significant differences were found
between the mannitol treated and the control groups, the confidence
intervals for the treatment effect estimates were wide and included
both clinically significant benefits and clinically significant
harms as possibilities.
 |
Reviewers Conclusions
|
|---|
There is currently not enough evidence to decide whether the
routine use of mannitol in acute stroke would result in any
beneficial or harmful effect. The routine use of mannitol in
all patients with acute stroke is not supported by any evidence
from randomized controlled clinical trials. Further trials are
needed to confirm or refute whether the routine use of mannitol
is beneficial in acute stroke. This is a brief summary of our
review with the full text available in the Cochrane Library.
2
 |
Acknowledgments
|
|---|
Disclosures
None.
Received June 15, 2007;
accepted June 20, 2007.
 |
References
|
|---|
- Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF; American Heart Association; American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007; 38: 1655–1711.[Abstract/Free Full Text]
- Bereczki D, Liu M, Prado GF, Fekete I. Mannitol for acute stroke (Cochrane Review). The Cochrane Database of Systematic Reviews, 2007, Issue 3.
This article has been cited by other articles:

|
 |

|
 |
 
E.S. Prakash
Is the Use of Hypertonic Mannitol Appropriate in the Management of Intracerebral Hemorrhage?
Stroke,
May 1, 2008;
39(5):
e85 - e85.
[Full Text]
[PDF]
|
 |
|

|
 |

|
 |
 
D. Bereczki, M. Liu, G. F. do Prado, and I. Fekete
Response to Letter by Prakash
Stroke,
May 1, 2008;
39(5):
e86 - e87.
[Full Text]
[PDF]
|
 |
|