Comparison of 20% mannitol and 3% hypertonic saline for intraoperative brain relaxation during supratentorial brain tumour craniotomy in patients with a midline shift

Purpose of the study

A prospective, randomized, double-blind study was designed to assess differences in brain relaxation between 20% mannitol and 3% hypertonic saline (HS) during elective supratentorial brain tumour surgery in patients with midline shift.

Material and methods

Sixty patients undergoing supratentorial craniotomy for tumour resection were enrolled to receive either 5 mL/kg of 20% mannitol (n = 30) or 3% HS (n = 30) administered at skin incision. P_CO2 in arterial blood was maintained within 35–40 mmHg and arterial blood pressure was controlled within baseline values ±20%. The primary outcome was the proportion of satisfactory brain relaxation. The surgeon assessed brain relaxation on a four-point scale (1 = excellent with no swelling, 2 = minimal swelling, 3 = serious swelling not requiring treatment, 4 = severe swelling requiring treatment). Postsurgical intracranial changes determined by imaging techniques, postoperative complications, PACU and hospital stay, and mortality at 30 days were also recorded. Appropriate statistical tests were used for comparison; P < 0.05 was considered as significant. This trial was registered in Eudract.ema.europa.eu (#2021-006290-40).

Results

There was no difference in brain relaxation: 2.00 [1.00–2.00] and 2.00 [1.75–3.00] for patients in mannitol and HS groups, respectively (P = 0.804). Tumour size (OR: 0.99, 95% CI: 0.99–1.01; P = 0.371), peritumoral oedema classification (OR: 0.57, 95% CI: 0.11–2.84; P = 0.493), mass effect (OR: 0.86, 95% CI: 0.16–4.87; P = 0.864), anaesthesia (OR: 4.88, 95% CI: 0.82–28.96; P = 0.081) and midline shift (OR: 5.00, 95% CI: 0.84–29.70; P = 0.077) did not have a significant influence on brain swelling in patients treated with either mannitol or HS. No significant differences in perioperative outcomes, mortality and length of PACU and hospital stay were observed.

Conclusions

5 mL/kg of 20% mannitol or 3% HS result in similar brain relaxation scores in patients undergoing craniotomy for supratentorial brain tumour with midline shift.