Efficacy and safety of hypertonic saline versus mannitol in the acute management of traumatic brain injury in the emergency department: a systematic review

Background: Hypertonic saline (HTS) and mannitol are used widely for raised intracranial pressure (ICP) after traumatic brain injury (TBI), but the preferred agent remains uncertain. This systematic review evaluated the efficacy and safety in acute TBI management. Methods: This review followed PRISMA principles. PubMed, Embase, Scopus, and Web of Science were searched for original studies comparing HTS or related hyperosmolar sodium solutions with mannitol in TBI. Eligible designs included randomized trials, prospective studies, retrospective cohorts, case-control studies, and multicenter observational studies. Outcomes included ICP reduction, cerebral perfusion pressure, neurological outcome, mortality, treatment failure, and adverse effects. Results: Thirteen original studies were included, most enrolled severe TBI patients with raised ICP. Both agents reduced ICP. Several studies reported physiological advantages with HTS, including lower ICP burden, improved cerebral perfusion pressure, better brain tissue oxygenation, faster target achievement, or lower treatment failure. Studies using similar osmotic burdens found comparable short-term ICP reduction. HTS increased serum sodium or osmolality in some studies, and mannitol was associated with greater urine output. Conclusion: HTS had physiological advantages, and the included studies does not prove better clinical outcome than mannitol.