Mannitol Use in Cerebrovascular Accident (CVA)

Indications for Mannitol in CVA

• The American Heart Association recommends osmotic therapy with mannitol for patients with clinical deterioration from cerebral swelling associated with cerebral infarction (Class IIa; Level of Evidence C) 2
• Mannitol is often used as a temporizing measure before patients undergo decompressive craniectomy 1

Dosing and Administration

• Intravenous mannitol (0.25 to 0.50 g/kg) administered over 20 minutes can be given every 6 hours 4
• The usual maximal dose is 2 g/kg 1

Efficacy and Limitations

• Despite its common use, a Cochrane systematic review found no evidence that routine use of mannitol reduced cerebral edema or improved stroke outcome in acute ischemic stroke 4
• No clinical evidence indicates that mannitol improves outcome in patients with ischemic brain swelling 1

Special Considerations

• Head position is important: the head of the bed should be elevated 20° to 30° to facilitate venous drainage 4
• The neck should be maintained in a neutral position to facilitate venous drainage 4
• For large hemispheric infarcts and hemorrhages, herniation rather than generalized increased ICP is the main concern, and ICP monitoring is generally not helpful 4

Alternative Treatments

• Surgical decompression (hemicraniectomy) is the most definitive treatment for massive cerebral edema 4
• A pooled analysis of randomized clinical trials showed that decompressive surgery performed within 48 hours of stroke onset reduced mortality and yielded more favorable outcomes 4