Timeline to consent prior to intervention start was unfeasible.

The study goal is to compare the management of increased intra-cranial pressure (ICP) using 3% hypertonic saline vs. mannitol (given in same osmolar loads).

Primary hypothesis:

1. Hypertonic saline will be non-inferior to mannitol in decreasing elevated ICP.

Secondary hypotheses:

1. Hypertonic saline therapy will result with fewer complications than mannitol
2. ICP reduction duration will be longer using hypertonic saline when compared with mannitol

There is growing evidence in the literature indicating that ICP and Cerebral Perfusion Pressure measurements may not be sufficient in the management of elevated ICP. Based on this evidence, monitoring of partial brain tissue oxygenation has gain acceptance among neurosurgeons and neurointensivists, and has become a standard of care monitor in some centers across the country. There is, however, insufficient information in the literature describing the effects of hyperosmolar medications on regional brain tissue oxygenation.

We intend to undertake this non-inferiority, prospective, randomized double-blind study to answer very important clinical questions not yet answered in the literature: Will hypertonic saline therapy, given at equiosmolar load, be non-inferior to mannitol in reducing elevated ICP?

Inclusion Criteria:

• Age ≥ 18 years
• elevated ICP requiring ICP monitoring
• ICP ≥ 25 mmHg 5 min after ICP bolt or EVD placement

Exclusion Criteria:

• Requiring decompressive craniotomy or post decompressive craniotomy
• Hyponatremia (sodium level < 125 mEq/L)
• Hypernatremia (sodium > 155 mmol/L)
• Serum osmolality ≤ 250 mOsm/kg
• Serum osmolality ≥ 320 mOsm/kg
• Physical exam compatible with brain death
• Patients on hemodialysis with end-stage renal disease