What is the indication of mannitol in cerebral (cerebellar) infarction?

From the Guidelines

Mannitol is indicated in cerebral (cerebellar) infarction for the management of cerebral edema and increased intracranial pressure, particularly in patients with clinical deterioration from cerebral swelling.

Key Points

• The use of mannitol in cerebral infarction is based on its ability to reduce intracranial pressure (ICP) through osmotic diuresis, with a typical dose of 0.25 to 0.5 g/kg IV administered over 20 minutes, which can be given every 6 hours 1.
• The American Heart Association/American Stroke Association recommends osmotic therapy, including mannitol, for patients with clinical deterioration from cerebral swelling associated with cerebral infarction, although the evidence is limited to Class IIa; Level of Evidence C 1.
• While mannitol can lower ICP, there is no evidence that it improves outcome in patients with ischemic brain swelling, and its use is often considered a temporizing measure before more definitive treatments, such as decompressive craniectomy, are undertaken 1.
• The monitoring of serum and urine osmolality is recommended when using mannitol to avoid potential complications 1.
• Other measures to manage cerebral edema and increased ICP in cerebral infarction include hyperventilation, hypertonic saline, and surgical interventions, such as decompressive surgery or drainage of cerebrospinal fluid 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 (cerebellar) infarction is for the reduction of intracranial pressure and brain mass 2.

From the Research

Indication of Mannitol in Cerebral Infarction

The use of mannitol in cerebral infarction is a topic of ongoing debate. According to the available evidence, mannitol is often used to treat cerebral edema associated with ischemic stroke. The following points summarize the indication of mannitol in cerebral infarction:

• Mannitol is used to reduce cerebral edema and intracranial pressure in patients with ischemic stroke 3, 4, 5, 6.
• The effects of mannitol on cerebral blood flow, blood volume, oxygen extraction fraction, and oxygen metabolism have been studied, with some studies suggesting that mannitol may increase cerebral blood flow in non-ischemic tissue 3.
• However, other studies have raised concerns about the safety and efficacy of mannitol in patients with acute ischemic stroke, suggesting that it may not improve functional outcomes and may even increase mortality 4, 5, 6.
• Animal studies have also suggested that repeated administration of mannitol may aggravate cerebral edema due to parenchymal accumulation of mannitol in the infarcted brain tissue 7.

Key Findings

Some key findings related to the indication of mannitol in cerebral infarction include:

• A study published in 2011 found that mannitol increased cerebral blood flow in the contralateral hemisphere, but not in the infarct core or periinfarct region 3.
• A study published in 2018 found that treatment with mannitol was associated with increased risk of in-hospital mortality in patients with acute ischemic stroke and cerebral edema 4.
• A systematic review published in 2007 found that there was not enough evidence to support the routine use of mannitol in acute stroke patients 5.
• Another systematic review published in 2000 found that the routine use of mannitol in all patients with acute stroke was not supported by evidence from randomized controlled clinical trials 6.