Hypertonic saline versus mannitol for brain relaxation
in supratentorial tumor surgery: a prospective
randomized trial

Eren Fatma Akcil; Ozlem Korkmaz Dilmen; Yusuf Tunali

doi:10.1016/j.bjane.2025.844684

Original Investigation

Hypertonic saline versus mannitol for brain relaxation in supratentorial tumor surgery: a prospective randomized trial

Soro hipertônico versus manitol para relaxamento cerebral em cirurgia de tumores supratentoriais: um ensaio prospectivo randomizado

Eren Fatma Akcil, Ozlem Korkmaz Dilmen, Yusuf Tunali

http://dx.doi.org/10.1016/j.bjane.2025.844684 Braz J Anesthesiol, vol.75, n6, 844684, 2025

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Abstract

Background

Hypertonic saline and mannitol are widely used to improve brain relaxation during supratentorial mass surgeries. Although continuous administration of hypertonic saline is known to reduce intracranial pressure, it has not yet been evaluated in supratentorial mass surgeries.

Methods

After institutional ethical committee approval, 92 patients scheduled for supratentorial craniotomy with glioblastoma multiforme, metastasis and/or midline shift (> 0.5 cm) were enrolled into this prospective, randomized, and double-blind study. The patients received hypertonic saline 3 mL.kg⁻¹ bolus, hypertonic saline infusion 20 mL.h⁻¹ or 20 % mannitol 0.6 gr.kg⁻¹ after head positioning. Brain relaxation score (1 = Perfectly relaxed, 2 = Satisfactorily relaxed, 3 = Firm brain and 4 = Bulging brain) was the primary outcome. Sodium and chlorine levels were the secondary outcomes. Postoperative brain edema and midline shift were assessed.

Results

After randomization, two patients were excluded from the study. Brain relaxation scores were higher with hypertonic saline bolus compared to mannitol (p = 0.047). The effect size between groups for brain relaxation score was 0.22. Hypertonic saline continuous infusion and mannitol were similar with respect to brain relaxation scores. Sodium and chlorine levels were lower in the mannitol group. Postoperative midline shift and edema were lower with continuous hypertonic saline compared to other groups (p = 0.001, p = 0.006).

Conclusion

Continuous infusion of 3 % hypertonic saline was associated with better relaxation scores in the intraoperative period and with lower incidences of edema/midline shift in the postoperative period of supratentorial mass surgeries with glioblastoma multiforme, metastasis and/or midline shift.

Keywords

Craniotomy; Glioblastoma; Mannitol

Resumo

Introdução

O soro hipertônico e o manitol são amplamente utilizados para melhorar o relaxamento cerebral durante cirurgias de massas supratentoriais. Embora a administração contínua de soro hipertônico seja conhecida por reduzir a pressão intracraniana, seu efeito ainda não foi avaliado especificamente em cirurgias de massas supratentoriais.

Métodos

Após aprovação pelo comitê de ética institucional, 92 pacientes programados para craniotomia supratentorial devido a glioblastoma multiforme, metástase e/ou desvio da linha média (> 0,5 cm) foram incluídos neste estudo prospectivo, randomizado e duplo-cego. Os pacientes receberam:

Bólus de soro hipertônico 3 mL.kg⁻¹,

Infusão contínua de soro hipertônico 20 mL.h⁻¹, ou

Manitol 20% 0,6 g.kg⁻¹, após o posicionamento da cabeça.

O desfecho primário foi a pontuação de relaxamento cerebral (Brain Relaxation Score): 1 = perfeitamente relaxado, 2 = satisfatoriamente relaxado, 3 = cérebro firme e 4 = cérebro saliente. Os desfechos secundários incluíram os níveis de sódio e cloro. O edema cerebral pós-operatório e o desvio da linha média também foram avaliados.

Resultados

Após a randomização, dois pacientes foram excluídos do estudo. As pontuações de relaxamento cerebral foram maiores com bólus de soro hipertônico em comparação ao manitol (p = 0,047). O tamanho do efeito entre os grupos para a pontuação de relaxamento cerebral foi 0,22. A infusão contínua de soro hipertônico e o manitol apresentaram pontuações de relaxamento cerebral semelhantes. Os níveis de sódio e de cloro foram menores no grupo manitol. O desvio da linha média e o edema pós-operatório foram menores com a infusão contínua de soro hipertônico em comparação aos outros grupos (p = 0,001; p = 0,006).

Conclusão

A infusão contínua de soro hipertônico 3% foi associada a melhores pontuações de relaxamento cerebral no período intraoperatório e a menor incidência de edema e desvio da linha média no período pós-operatório de cirurgias de massas supratentoriais envolvendo glioblastoma multiforme, metástase e/ou desvio da linha média.

Palavras-chave

Craniotomia; Glioblastoma; Manitol

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Submitted date:
06/02/2025

Accepted date:
31/08/2025