Effect of mannitol on regional cerebral blood flow in patients with intracerebral hemorrhage J. Kalita a , U.K. Misra a, * , P. Ranjan a , P.K. Pradhan b , B.K. Das b a Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareily Road, Lucknow 226014, India b Department of Nuclear Medicine, Sanjay Gandhi PGIMS, Lucknow, India Received 26 September 2003; received in revised form 29 April 2004; accepted 5 May 2004 Available online 7 August 2004 Abstract Aim: To evaluate the regional cerebral blood flow (rCBF) changes following IV mannitol bolus in patients with intracerebral hemorrhage (ICH). Methods: In a hospital based randomized placebo controlled study, 21 CT proven ICH patients with Glasgow coma scale (GCS) score of 5 or more were subjected to clinical evaluation including GCS and Canadian Neurological stroke (CNS) scale. Cranial SPECT study was undertaken before and 60 min after 20% mannitol 100 ml IV in 20 min or sham infusion. The SPECT images were semi-quantitatively analyzed and asymmetry index of basal ganglia, frontal, parietal and occipital regions were calculated. Results: There were 12 patients in mannitol and nine in control group who were evenly matched for age, mean arterial blood pressure, GCS score and size of hematoma. Only one patient died in mannitol group. Following mannitol, GCS score improved in six, worsened in two and remained unaltered in four patients. In the control group, GCS improved in seven, worsened in none and was unchanged in two patients. SPECT studies revealed reduction in asymmetry index in basal ganglia in four, frontal region in six, parietal in four and occipital region in five patients in mannitol group. In control group, asymmetry index was reduced in basal ganglia in one, frontal and parietal region in three each and occipital region in five patients. These differences between control and study group were not significant. Conclusion: Mannitol does not seem to significantly change the regional cerebral blood flow (rCBF) in ICH patients as evaluated by SPECT study. D 2004 Elsevier B.V. All rights reserved. Keywords: Mannitol; Regional cerebral blood flow; Intracerebral hemorrhage 1. Introduction In the acute stage, stroke-related mortality is attributed to brain herniation. Raised intracranial pressure (ICP) results in cerebral blood flow alterations, which may even result in brain infarction. Lowering the intra cranial pressure is crucial for the management of acute stroke. Mannitol has been used in the management of acute stroke since long time. American Heart Association has recommended it for the management of spontaneous intracerebral hemorrhage (ICH) with type B ICP waves, progressively increasing ICP and clinical deteriora- tion due to mass effect [1]. About 70% of physicians in China use mannitol or glycerol in acute stroke [2]. Mannitol is also used routinely in several European centers and is listed amongst the therapeutic interventions in the consensus statement of Hungarian stroke society for the patients where raised ICP is proven in stroke [3]. A survey of prescribing pattern of anti edema measure in stroke in Indian physicians and neurologists revealed its universal use [4]. In spite of this widespread use, there is limited scientific information available regarding its benefit and the possible mechanism in stroke. In a study on six patients with acute middle cerebral arterial infarction and CT evidence of midline shift, the effect of intravenous bolus of mannitol was evaluated. At 50–55 min after the baseline scan, total brain volume significantly decreased but the non-infarcted hemisphere shrank more than 0022-510X/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.jns.2004.05.019 * Corresponding author. Fax: +91-522-2668017. E-mail addresses: ukmisra@sgpgi.ac.in, ukmisra@indiatimes.com (U.K. Misra). Journal of the Neurological Sciences 224 (2004) 19 – 22 www.elsevier.com/locate/jns