Aneurysmal subarachnoid hemorrhage (aSAH) tended to lead to a sudden increase in intracerebral pressure (ICP), which can cause decreased cerebral perfusion and transient global cerebral ischemia. Early clipping and coiling of aneurysms and surgical evacuation of intracerebral hematoma were recommended for aSAH patients. However, the high ICP made it difficult to separate the subarachnoid space during the operation. Effective reduction of ICP was the key to the succession of the operation. But there is a lack of consensus on the management of raised ICP in aSAH. Mannitol is widely used to reduce ICP in patients with cerebral edema. The potential mechanism including decreasing the viscosity of the blood improving regional cerebral microvascular flow and oxygenation and increasing intravascular volume due to increased plasma osmolality. The magnitude of the pressure reduction was correlated with the intact intracranial automatic adjustment function. However, the hypochloremic metabolic alkalosis, hypernatremia, hypokalemia and renal failure associated with mannitol overdose must be considered and the effective dose and the duration of its administration were still unknown. The aims of this study were to determine the most appropriate mannitol dose to provide adequate brain relaxation in aSAH patients with the fewest adverse effects.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
TRIPLE
Enrollment
99
When the neurosurgeon starts the skin incision, 20% mannitol administered through the venous catheter with fulldrip in 5-10 minutes. Neurosurgeons evaluate the degree of brain relaxation after dura opening in 4 point scale (1=bulging brain, 2=firm brain, 3=satisfactorily relaxed, 4=perfectly relaxed).
Capital Medical University Affiliated Beijing Tiantan Hospital
Beijing, Beijing Municipality, China
Brain relaxation score
The degree of brain relaxation after administration was assessed as four grades. denoting bulging or the condition that additional methods for brain relaxation are immediately and always required in order to continue the surgical procedure because of brain swelling; firm or the condition that additional methods for brain relaxation are occasionally required to continue the surgical procedure; adequate; perfectly relaxed. All patients received conventional frontotemporal pterional approach, and the time from skin incision to dural opening was constant for 30 minutes. At the time of dural opening, the degree of cerebral relaxation was evaluated, and the satisfactory cerebral relaxation was defined as 3 or 4 points.
Time frame: Intraoperative
electrolyte change (potassium)
Check the serum laboratory result of potassium (normal range: 3.4-4.5 mmol/L)
Time frame: before the infusion of mannitol and 30 minutes after the administration of the study drug.
electrolyte change (sodium)
Check the serum laboratory result of sodium (normal range: 136-146 mmol/L)
Time frame: before the infusion of mannitol and 30 minutes after the administration of the study drug.
electrolyte change (chlorine)
Check the serum laboratory result of chlorine (normal range: 98-106 mmol/L)
Time frame: before the infusion of mannitol and 30 minutes after the administration of the study drug.
electrolyte change (calcium)
Check the serum laboratory result of calcium (normal range: 1.15-1.29 mmol/L)
Time frame: before the infusion of mannitol and 30 minutes after the administration of the study drug.
Subdural hematoma
Excessive decrease in intracranial pressure may lead to intraoperative or postoperative subdural hematoma formation
Time frame: CT scan 6 hours after surgery
modified Rankin Score 3 months after surgery
To evaluate the potential benefits of effective dural lysis and brain relaxation on patient outcomes. The scale runs from 0-6, running from perfect health without symptoms to death. 0 - No symptoms. 1 - No significant disability. Able to carry out all usual activities, despite some symptoms. 2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities. 3 - Moderate disability. Requires some help, but able to walk unassisted. 4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted. 5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent. 6 - Dead.
Time frame: 3 months after surgery
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