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Salt or sugar for your injured brain? A meta-analysis of randomised controlled trials of mannitol versus hypertonic sodium solutions to manage raised intracranial pressure in traumatic brain injury
  1. A C Rickard1,
  2. J E Smith2,
  3. P Newell3,
  4. A Bailey3,
  5. A Kehoe1,
  6. C Mann4
  1. 1Emergency Department, Derriford Hospital, Plymouth, UK
  2. 2Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
  3. 3Centre for Biostatistics, Bioinformatics and Biomarkers, Plymouth University, Plymouth, UK
  4. 4Emergency Department, Musgrove Park Hospital, Taunton, UK
  1. Correspondence to Dr Annette Rickard, Emergency Department, Derriford Hospital, Crownhill, Plymouth, PL6 8DH, UK; annette.rickard{at}


Background Rising intracranial pressure (ICP) is a poor prognostic indicator in traumatic brain injury (TBI). Both mannitol and hypertonic sodium solutions are used to treat raised ICP in patients with TBI.

Objective This meta-analysis compares the use of mannitol versus hypertonic sodium solutions for ICP control in patients with TBI.

Data sources and study eligibility Randomised clinical trials in adults with TBI and evidence of raised ICP, which compare the effect on ICP of hypertonic sodium solutions and mannitol.

Methods The primary outcome measure is the pooled mean reduction in ICP. Studies were combined using a Forest plot.

Results Six studies were included, comprising 171 patients (599 episodes of raised ICP). The weighted mean difference in ICP reduction, using hypertonic sodium solutions compared with mannitol, was 1.39 mm Hg (95% CI −0.74 to 3.53).

Limitations Methodological differences between studies limit the conclusions of this meta-analysis.

Conclusions The evidence shows that both agents effectively lower ICP. There is a trend favouring the use of hypertonic sodium solutions in patients with TBI.

  • Trauma, Head
  • Treatment

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