What is the indication of mannitol in cerebral infarct?

From the Guidelines

Mannitol is indicated in cerebral infarct for the management of increased Intracranial Pressure (ICP), specifically in cases where cerebral edema is present.

Key Points

• The usual dose of mannitol is 0.25 to 0.5 g/kg IV administered over 20 minutes, which can be given every 6 hours 1.
• Mannitol works by creating an osmotic gradient, drawing water out of neurons into arteries, leading to vasoconstriction and reduced cerebrovascular volume 1.
• While mannitol can lower ICP, there is no evidence that it improves outcome in patients with ischemic brain swelling 1.
• Other measures to manage increased ICP include hyperventilation, hypertonic saline, intraventricular drainage of cerebrospinal fluid, and decompressive surgery 1.
• The management of cerebral edema should also focus on preventing further deterioration from tissue displacement and brain stem shift, and correcting factors that could exacerbate swelling such as hypoxemia, hypercarbia, and hyperthermia 1.

From the FDA Drug Label

Mannitol Injection is indicated for the following purposes in adults and pediatric patients. Therapeutic Use Reduction of intracranial pressure and brain mass. Reduction of high intraocular pressure. Diagnostic Use Measurement of glomerular filtration rate.

The indication of mannitol in cerebral infarct is reduction of intracranial pressure and brain mass. 2 2

From the Research

Indication of Mannitol in Cerebral Infarct

The indication of mannitol in cerebral infarct is primarily for the treatment of cerebral edema associated with ischemic stroke. Key points to consider include:

• Mannitol is an osmotic agent that may help reduce cerebral edema and tissue damage in stroke patients 3, 4, 5, 6.
• Current guidelines suggest that osmotic therapy, including mannitol, is reasonable in patients with clinical deterioration from cerebral infarction-related cerebral edema 3.
• However, studies have shown that the use of mannitol in acute ischemic stroke may not improve functional outcomes and could potentially increase mortality 3, 4, 5, 6.

Efficacy and Safety of Mannitol

The efficacy and safety of mannitol in cerebral infarct are not well established, with limited data available from randomized controlled trials. Key findings include:

• A study published in 2018 found that treatment with mannitol was associated with increased risk for in-hospital mortality in patients with acute ischemic stroke and cerebral edema 3.
• Cochrane reviews published in 2001,2007, and 2000 found that there was not enough evidence to support the routine use of mannitol in acute stroke patients, due to the limited number of trials and participants 4, 5, 6.
• An animal study published in 1997 found that repeated mannitol infusions reduced brain water content in a rat model of cortical infarction, but the relevance of this finding to human patients is unclear 7.

Clinical Use of Mannitol

The clinical use of mannitol in cerebral infarct should be approached with caution, given the limited evidence available. Key considerations include:

• Mannitol may be considered for use in patients with severe cerebral edema and clinical deterioration, but its use should be carefully monitored and weighed against potential risks 3.
• Further research is needed to fully understand the effects of mannitol in acute stroke and to determine its potential benefits and harms 4, 5, 6.