Hypertonic Saline Dosing for Intracerebral Hemorrhage
For intracerebral hemorrhage with elevated intracranial pressure, administer 3% hypertonic saline as a continuous infusion targeting serum sodium of 145-155 mmol/L, or use 7.5% hypertonic saline 250 mL bolus (approximately 2 mL/kg) over 15-20 minutes for acute ICP crises. 1
Bolus Dosing Strategy
For acute ICP elevation or threatened herniation:
- 7.5% hypertonic saline: 250 mL bolus administered over 15-20 minutes 1
- Alternative dosing: 2 mL/kg of 7.5% solution 2
- 23.4% hypertonic saline: 0.7 mL/kg for more concentrated bolus therapy 3
- Maximum ICP reduction occurs at 10-15 minutes, with effects lasting 2-4 hours 1
Re-dosing parameters:
- Do not re-administer until serum sodium is <155 mmol/L 1
- Typical re-dosing interval when needed: 163 ± 54 minutes after previous bolus 2
- Measure serum sodium within 6 hours of bolus administration 1
Continuous Infusion Strategy
For sustained ICP management in ICH:
- 3% hypertonic saline continuous infusion is the preferred approach 1
- Target serum sodium: 145-155 mmol/L 1
- Target osmolality: 310-320 mOsm/kg 4
- Initiate within ≤72 hours of symptom onset for optimal benefit 4
- Mean treatment duration: 13 days (range 4-23 days) 4
The continuous infusion strategy has demonstrated superior outcomes in ICH patients, with fewer ICP crises (92 vs 167 episodes, p=0.027) and reduced in-hospital mortality (17.0% vs 29.6%, p=0.037) compared to historical controls 4. This approach produced significantly higher cerebral perfusion pressure and lower water content in lesioned white matter compared to mannitol 3.
Comparative Efficacy
3% hypertonic saline demonstrates superior properties over mannitol:
- More sustained ICP reduction, with ICP remaining significantly lower at 120 minutes post-treatment (only 3% NaCl maintained significance, p=0.02) 3
- Higher cerebral perfusion pressure (108.4 ± 4 vs 79.6 ± 10 mm Hg, p=0.048) compared to mannitol 3
- Requires smaller volume (1.4 mL/kg for 3% HTS vs 2.0 mL/kg for 20% mannitol) 5
- Faster ICP reduction (16 minutes vs 23 minutes for mannitol) 5
For patients with therapy-resistant ICP (>25 mm Hg despite standard management), 7.5% hypertonic saline boluses reduced ICP from 33 ± 9 mm Hg to 19 ± 6 mm Hg within one hour 2.
Safety Monitoring
Critical monitoring parameters:
- Serum sodium measurement within 6 hours of bolus administration 1
- Maintain sodium <155 mmol/L to prevent complications 1
- Monitor fluid, sodium, and chloride balances 1
- Avoid exceeding 155-160 mmol/L to prevent hypernatremia complications 1
No evidence of osmotic demyelination syndrome has been reported with proper monitoring, even with bolus doses of 23.4% hypertonic saline or sustained hypernatremia 1. Rapid peripheral administration at rates up to 999 mL/h did not result in extravasation or phlebitis 6.
Clinical Context and Limitations
Important caveats:
- Despite robust efficacy in reducing ICP (Grade A evidence), hypertonic saline does not improve neurological outcomes (Grade B) or survival (Grade A) in patients with raised intracranial pressure 1
- The European Stroke Organisation notes insufficient RCT evidence to make strong recommendations on ICP-lowering measures in ICH 1
- Hypertonic saline should be used as a temporizing measure or bridge to definitive surgical intervention when indicated 7
Preferred over mannitol in specific scenarios:
The evidence base for hypertonic saline in ICH is more limited compared to traumatic brain injury, but one nonrandomized feasibility study showed 3% hypertonic saline led to less perihematomal edema and a mortality trend favoring treatment 1.