Pasarikovski Christopher R, Alotaibi Naif M, Al-Mufti Fawaz, Macdonald R Loch
Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
World Neurosurg. 2017 Sep;105:1-6. doi: 10.1016/j.wneu.2017.05.085. Epub 2017 May 23.
The use of hyperosmolar agents, such as mannitol or hypertonic saline (HTS), to control high intracranial pressure (ICP) in patients with traumatic brain injury has been well studied. However, the role of HTS in the management of aneurysmal subarachnoid hemorrhage (aSAH)-associated increased ICP is still unclear.
We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome of this review is to quantify ICP reduction produced by HTS and its effect on clinical outcomes defined by any standardized functional score. Secondary outcomes included HTS versus mannitol in ICP reduction, HTS effects on cerebral vasospasm, and HTS dose concentration, infusion rate, infusion volume, frequency of redosing, and serum sodium/osmolality limits for repeat dosing.
Five studies were included in the review encompassing 175 patients. Studies on aSAH included mostly poor grade patients (defined as World Federation of Neurosurgical Societies grade 4 and 5). HTS concentrations ranged from 3%-23.5%. Most studies found that HTS decreased ICP when compared with either baseline or placebo. The mean decrease in ICP from HTS administration was 8.9 mm Hg (range: 3.3-12.1 mm Hg). Only 1 study showed possible improvement in poor grade aSAH outcomes.
The current evidence suggests that HTS is as effective as mannitol at reducing increased ICP in aSAH. However, there is not enough data to recommend the optimal and safest dose concentration or whether HTS significantly improves outcomes in aSAH.
使用高渗药物，如甘露醇或高渗盐水（HTS），来控制创伤性脑损伤患者的高颅内压（ICP）已得到充分研究。然而，HTS在动脉瘤性蛛网膜下腔出血（aSAH）相关的ICP升高管理中的作用仍不清楚。
我们按照系统评价和Meta分析的首选报告项目指南进行了系统评价。本评价的主要结果是量化HTS降低ICP的程度及其对由任何标准化功能评分定义的临床结局的影响。次要结果包括HTS与甘露醇在降低ICP方面的比较、HTS对脑血管痉挛的影响以及HTS的剂量浓度、输注速率、输注量、再次给药频率以及重复给药的血清钠/渗透压限值。
该评价纳入了五项研究，共175例患者。关于aSAH的研究大多纳入了病情较差的患者（定义为世界神经外科协会联盟4级和5级）。HTS浓度范围为3%-23.5%。大多数研究发现，与基线或安慰剂相比，HTS可降低ICP。HTS给药后ICP的平均降低幅度为8.9 mmHg（范围：3.3-12.1 mmHg）。只有1项研究显示病情较差的aSAH患者的结局可能有所改善。
目前的证据表明，HTS在降低aSAH患者升高的ICP方面与甘露醇一样有效。然而，没有足够的数据推荐最佳和最安全的剂量浓度，也无法确定HTS是否能显著改善aSAH患者的结局。
