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Overlapping Hyperosmolar Therapy in Patients With Elevated and Refractory Intracranial Pressure
Madelyn J Johnson1, Caitlin S Brown1,2, Alejandro A Rabinstein3
1Department of Pharmacy.
Clinical Neuropharmacology
|July 1, 2026
Summary
Overlapping hyperosmolar therapy, using mannitol and hypertonic sodium, may transiently reduce intracranial pressure (ICP) in acute brain injury patients. This approach showed a potential benefit without significant adverse events.
Area of Science:
- Neuroscience
- Critical Care Medicine
- Pharmacology
Background:
- Elevated intracranial pressure (ICP) is a critical concern in acute brain injury.
- Current treatments often involve single hyperosmolar agents.
- The safety and efficacy of combining hyperosmolar agents for ICP management are not well-established.
Purpose of the Study:
- To investigate the ICP-lowering effects of overlapping hyperosmolar therapy.
- To evaluate the safety profile of using mannitol and hypertonic sodium concurrently.
- To analyze outcomes in patients with refractory intracranial hypertension.
Main Methods:
- Retrospective, single-center study of adult patients with acute brain injury and intracranial hypertension.
- Inclusion criteria: ICP monitor, refractory to single hyperosmolar agent.
- Treatment involved overlapping doses of mannitol and hypertonic sodium every ~3 hours.
Main Results:
- 86% of patients showed ICP reduction after initiating overlapping therapy.
- Six cases of acute kidney injury and 7 of pulmonary edema were observed.
- Median peak sodium, chloride, and osmolar gap were 149 mEq/L, 115 mEq/L, and 5.7 mOsm/kg, respectively.
Conclusions:
- Overlapping hyperosmolar therapy may offer transient ICP reduction in refractory cases.
- The therapy appears to have a manageable safety profile.
- Further research is warranted to optimize this treatment strategy.
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