EXPRESS: Comparing hypertonic saline and mannitol for management of elevated intracranial pressure in adults: A PRISMA-compliant systematic review and meta-analysis

This systematic review and meta-analysis aimed to compare the efficacy of mannitol and hypertonic saline (HTS) in reducing elevated intracranial pressure (ICP). We conducted a comprehensive search of multiple databases to identify eligible trials comparing HTS and mannitol in adults with elevated ICP; only studies that used ICP monitoring to obtain objective measurements were included. The primary outcome was the change in ICP at different time points, and secondary outcomes included changes in other clinical indicators. A total of 16 studies (583 patients, 2,219 episodes) were included. The pooled results showed that HTS was significantly more effective than mannitol in reducing ICP at 30 min, 1 h, and 3 h post-intervention. However, the numerical differences were small. And there were no statistically significant differences between HTS and mannitol groups in ICU length of stay, mortality, or unfavorable Glasgow Outcome Scale (GOS) scores. In addition, the increases in cerebral perfusion pressure (CPP), mean arterial pressure (MAP), and serum sodium were significantly greater in the HTS group than in the mannitol group at various time points. While HTS produced a larger ICP-lowering effect, the statistically significant difference was modest. Accordingly, existing synthesized evidence fails to clearly establish whether HTS is superior or inferior to mannitol for reducing intracranial pressure.