TREATMENT OF REFRACTORY INTRACRANIAL HYPERTENSION WITH 23.4-PERCENT SALINE

Objective: To evaluate the effect of intravenous bolus administration of 23.4% saline (8008 mOsm/L) on refractory intracranial hypertension (RIH) in patients with diverse intracranial diseases. Design: Retrospe ctive chart review. Setting: A neurosciences intensive care unit in a university hospital. Patients: We present eight patients and a total o f 20 episodes of increased intracranial pressure (ICP) resistant to st andard modes of therapy. Five patients had subarachnoid hemorrhage, on e patient had traumatic brain injury, one had a brain tumor, and anoth er had spontaneous basal ganglia hemorrhage. Seven patients had intrav entricular catheters, and one had a subarachnoid pressure screw placed . We monitored continuously mean ICP, serum sodium concentrations, mea n arterial pressure, cerebral perfusion pressure (CPP), central venous pressure, and urine output before and after the administration of hyp ertonic saline (HS). Post mortem examination of the brain was performe d in two patients. Intervention: Intravenous bolus administration of 3 0 mt of 23.4% saline. Measurements and Main Results: There was a signi ficant (p <.05) decrease in ICP from a median of 41.5 mm Hg before HS to 17 mm Hg at 1 hr, 16 mm Hg at 2 hrs, and 14 mm Hg at 3 hrs after HS administration. In 80% of cases, ICP decreased by >50% of the pretrea tment value over a duration of 21.2 +/-: 10.3 mins. ICP decreased to < 20 mm Hg in 65% of all cases and the mean time for it to again exceed 20 mm Hg was 6.3 +/- 4.9 hrs. There was a significant improvement in C PP, from 64.7+/-19 (SD) mm Hg before HS to 85.6 +/- 18 mm Hg (1 hr) an d 83 +/- 18 mm Hg (3 hrs) after HS. There were no significant differen ces in the other variables measured. The post mortem examinations show ed no white matter changes or subdural collections. Conclusions: This preliminary case series suggests that the intravenous bolus administra tion of 23.4% saline reduces ICP and augments CPP in patients with res istant increased ICP. This reduction can be maintained for several hou rs while other therapeutic measures are being considered. The patient population most likely to respond to this therapy needs to be further defined. Although more research is needed, this treatment is promising as a new modality for RIH because of its ICP-lowering effect without intravascular volume depletion.