Background: Mannitol infusion is widely used in clinical practice to reduce perilesional edema in intracerebral hemorrhage (ICH), though no controlled studies have yet provided evidence of its effects on clinical outcome or on cerebral blood flow impairment following the event. The aim of our study was to evaluate blood flow velocity changes in the middle cerebral arteries (MCA) after a mannitol bolus in patients with ICH. Methods: Transcranial Doppler bilateral monitoring was performed for 90 min in 20 patients with ICH, during 100 ml mannitol bolus i.v. administration. The MCA mean flow velocities (MFVs) and pulsatility index (PI) were recorded. Results: When the ‘healthy’ and the ‘affected’ hemispheres were compared, we observed higher MCA MFV and lower PI on the affected side than on the contralateral side, both at baseline and during the experiment. After the mannitol bolus, we observed a significant MFV increase, starting at the end of the infusion and lasting longer than 60 min in the MCA on the affected side alone. The PI increased after mannitol administration on the healthy side alone. Conclusions: A single bolus of mannitol modified cerebral hemodynamics in our patients with ICH, increasing flow velocities on the affected MCA. This effect may be a consequence of reduced edema in the perilesional areas. The increased PI on the unaffected side may be indicative of preserved pulsatility in the healthy hemisphere.

1.
Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF: Spontaneous intracerebral hemorrhage. N Engl J Med 2001;344:1450–1460.
2.
Schierhout G, Roberts I: Mannitol in acute traumatic brain injury. Cochrane Database Syst Rev.
3.
Woster PS, LeBlanc KL: Management of elevated intracranial pressure. Clin Pharm 1990;9:762–772.
4.
Andrews RJ, Bringas JR, Muto RP: Effects of mannitol on cerebral blood flow, blood pressure, blood viscosity, hematocrit, sodium and potassium. Surg Neurol 1993;39:218–222.
5.
Bereczki D, Mihálka L, Szatmári S, Fekete K, Di Cesar D, Fülesdi B, Csiba L, Fekete I: Mannitol use in acute stroke: case fatality at 30 days and 1 year. Stroke 2003;34:1730–1735.
6.
Cruz J, Minoja G, Okuchi K: Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe haemorrhages with abnormal papillary widening: a randomized trial. Neurosurgery 2002;51:628–637.
7.
Cruz J, Minoja G, Okuchi K, Facco E: Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale score of 3 and bilateral abnormal pupillary widening: a randomized trial. J Neurosurg 2004;100:376–383.
8.
Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ, Stroke Council of the American Stroke Association: Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34:1056–1083.
9.
Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee. Cerebrovasc Dis 2008;25:457–507.
10.
Bereczki D, Fekete I, Prado GF, Liu M: Mannitol for acute stroke. Cochrane Database Syst Rev 2007;CD001153.
11.
Prakash ES: Is the use of hypertonic mannitol appropriate in the management of intracerebral hemorrhage? Stroke 2008;39:e85, author’s reply e86–e87.
12.
Aries MJ, Elting JW, De Keyser J, Kremer BP, Vroomen PC: Cerebral autoregulation in stroke: a review of transcranial Doppler studies. Stroke 2010;41:2697–2704.
13.
Aaslid R: Cerebral autoregulation and vasomotor reactivity. Front Neurol Neurosci 2006;21:216–228.
14.
Braderick JP, Brott TG, Duldner JE, Tomsick T, Huster G: Volume of intracerebral hemorrhage: a powerful and easy to use predictor of 30 days mortality. Stroke 1993;24:987–993.
15.
Vicenzini E, Pro S, Strano S, Pulitano P, Altieri M, Di Piero V, Lenzi GL, Accornero N, Mecarelli O: Combined transcranial Doppler and EEG recording in vasovagal syncope. Eur Neurol 2008;60:258–263.
16.
Vicenzini E, Ricciardi MC, Altieri M, Puccinelli F, Bonaffini N, Di Piero V, Lenzi GL: Cerebrovascular reactivity in degenerative and vascular dementia: a transcranial Doppler study. Eur Neurol 2007;58:84–89.
17.
Gosling RG, King DH: Arterial assessment by Doppler-shift ultrasound. Proc R Soc Med 1974;67:447–449.
18.
Klijn CJ, Hankey GJ, American Stroke Association and European Stroke Initiative: Management of acute ischaemic stroke: new guidelines from the American Stroke Association and European Stroke Initiative. Lancet Neurol 2003;2:698–670.
19.
Baron JC, Delattre JY, Bories J, Chiras J, Cabanis EA, Blas C, Bousser MG, Comar D: Comparison study of CT and positron emission tomographic data in recent cerebral infarction. AJNR Am J Neuroradiol 1983;4:536–540.
20.
Spreafico G, Cammelli F, Gadola G, Freschi R, Zancaner F: Luxury perfusion syndrome in cerebral vascular disease evaluated with technetium-99m HM-PAO. Clin Nucl Med 1987;12:217–218.
21.
Moretti JL, Defer G, Cinotti L, Cesaro P, Degos JD, Vigneron N, Ducassou D, Holman BL: ‘Luxury perfusion’ with 99mTc-HMPAO and 123I-IMP SPECT imaging during the subacute phase of stroke. Eur J Nucl Med 1990;16:17–22.
22.
Di Piero V, Perani D, Savi A, Gerundini P, Lenzi GL, Fazio F: Sequential assessment of regional cerebral blood flow, regional cerebral blood volume, and blood-brain barrier in focal cerebral ischemia: a case report. J Cereb Blood Flow Metab 1986;6:379–384.
23.
Zanette EM, Roberti C, Mancini G, Pozzilli C, Bragoni M, Toni D: Spontaneous middle cerebral artery reperfusion in ischemic stroke. A follow-up study with transcranial Doppler. Stroke 1995;26:430–433.
24.
Toni D, Fiorelli M, Zanette EM, Sacchetti ML, Salerno A, Argentino C, Solaro M, Fieschi C: Early spontaneous improvement and deterioration of ischemic stroke patients. A serial study with transcranial Doppler ultrasonography. Stroke 1998;29:1144–1148.
25.
Michel E, Zernikow B: Gosling’s Doppler pulsatility index revisited. Ultrasound Med Biol 1998;24:597–599.
26.
Aaslid R, Markwalder TM, Nornes H: Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 1982;57:769–774.
27.
Kalita J, Misra UK, Ranjan P, Pradhan PK, Das BK: Effect of mannitol on regional cerebral blood flow in patients with intracerebral haemorrhage. J Neurol Sci 2004;224:19–22.
28.
Videen TO, Zazulia AR, Manno EM, Derdeyn CP, Adams RE, Diringer MN, Powers WJ: Mannitol bolus preferentially shrinks non-infarcted brain in patients with ischemic stroke. Neurology 2001;57:2120–2122.
29.
Misra UK, Kalita J, Vajpayee A, Phadke RV, Hadique A, Savlani V: Effect of single mannitol bolus in intracerebral hemorrhage. Eur J Neurol 2007;14:1118–1123.
30.
Paczynski PP, Hee YY, Diringer MN, Hsu EY: Multiple dose mannitol reduces brain water content in a rat model of cortical infarction. Stroke 1997;28:1437–1444.
31.
Arima H, Wang JG, Huang Y, Heeley E, Skulina C, Parsons MW, Peng B, Li Q, Su S, Tao QL, Li YC, Jiang JD, Tai LW, Zhang JL, Xu E, Cheng Y, Morgenstern LB, Chalmers J, Anderson CS, INTERACT Investigators: Significance of perihematomal edema in acute intracerebral hemorrhage: the INTERACT trial. Neurology 2009;73:1963–1968.
32.
Krejza J, Chen R, Romanowicz G, Kwiatkowski JL, Ichord R, Arkuszewski M, Zimmerman R, Ohene-Frempong K, Desiderio L, Melhem ER: Sickle cell disease and transcranial Doppler imaging. Inter-hemispheric differences in blood flow Doppler parameters. Stroke 2011;42:81–86.
33.
Diringer MN, Scalfani MT, Zazulia AR, Videen TO, Dhar R: Cerebral hemodynamic and metabolic effects of equi-osmolar doses mannitol and 23.4% saline in patients with edema following large ischemic stroke. Neurocrit Care 2011;14:11–17.
34.
Gebel JM Jr, Jauch EC, Brott TG, Khoury J, Sauerbeck L, Salisbury S, Spilker J, Tomsick TA, Duldner J, Broderick JP: Relative edema volume is a predictor of outcome in patients with hyperacute spontaneous intracerebral hemorrhage. Stroke 2002;33:2636–2641.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.