Hypertonic Saline 75% vs Mannitol 20%
Condition: Brain Tumor; Tumor, Brain; Brain Neoplasm; Neoplasm, Supratentorial; Tumor, Supratentorial
MeSH terms: Neoplasms; Brain Neoplasms; Supratentorial Neoplasms
Study type: Interventional

Summary: 
      The purpose of this study is to evaluate the effect of Hypertonic Saline 7.5% vs Mannitol 20%
      on brain bulk (using a 4 point scale), intracranial pressure (subdural catheter)and the
      changes on serum and urinary Na, K and Osmolarity during elective craniotomy for brain tumor
      resection.
    

Detailed description: 
      Raised intracranial pressure occurs following an expansion of an intracranial mass e.g.
      hematoma or brain tumor and if left untreated, can lead to brain ischemia, stroke and death.

      Strategies for reducing raised intracranial pressure include hyperventilation, use of a
      hyperosmolar agent and the evacuation of the intracranial mass.

      The two hypertonic solutions most commonly used are Mannitol 20% and Hypertonic Saline 7.5%.

      During elective neurosurgical removal of a brain tumour, the anesthesiologist needs to reduce
      intracranial pressure and provide good operating brain conditions to avoid brain ischemia.

      Currently, Mannitol 20% is routinely used intra-operatively in these patients to reduce brain
      bulk and intracranial pressure and to improve brain operating conditions.

      However, Mannitol itself can cause secondary effects that can be deleterious to the
      neurological patient. Mannitol causes a diuresis which may lead to systemic hypovolemia and
      hypotension, and adverse changes in serum and urinary sodium, potassium and osmolarity.

      Experience with Hypertonic saline 7.5%, has been mainly in brain injured patients either in
      the Emergency Dept or in the Intensive care setting. There is growing evidence that
      Hypertonic saline 7.5% is just as effective as Mannitol 20% in reducing raised intracranial
      pressure, especially in traumatic brain injury and it has become a widely accepted form of
      treatment. One of the advantages of Hypertonic saline is that it does not cause a diuresis
      and therefore less likely to cause hypotension and hypovolemia. While transient hypernatremia
      has been observed after the administration of hypertonic saline, there have been no clinical
      consequences.

      Unfortunately there have been only two studies which compared the effectiveness of Hypertonic
      saline and Mannitol during elective brain surgery. One of them, Gemma et al, failed to
      demonstrate any difference in the reduction of brain bulk between Mannitol and Hypertonic
      saline. However the 2 solutions used had different osmolarities and this may have had a
      confounding effect on the results. In the other study (published in Polish), the authors
      found a 20% reduction in brain bulk in favour of hypertonic saline. In view of these two
      opposing findings, we feel that another investigation is warranted.
    

Intervention name(s): Administration of Hypertonic Solution 7.5% vs Mannitol 20%
Intervention type(s): Drug
Intervention MeSH terms: Mannitol
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double
Primary purpose: Treatment
Keywords: Brain Tumor; Intracranial Pressure; Osmolarity; Seric; Hypertonic Solution