Fluid Management in Acute Brain Injury

  • Sandra RossiEmail author
  • Edoardo Picetti
  • Tommaso Zoerle
  • Marco Carbonara
  • Elisa R Zanier
  • Nino Stocchetti
Critical Care (S Mayer, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Critical Care


Purpose of the Review

The aims of fluid management in acute brain injury are to preserve or restore physiology and guarantee appropriate tissue perfusion, avoiding potential iatrogenic effects. We reviewed the literature, focusing on the clinical implications of the selected papers. Our purposes were to summarize the principles regulating the distribution of water between the intracellular, interstitial, and plasma compartments in the normal and the injured brain, and to clarify how these principles could guide fluid administration, with special reference to intracranial pressure control.

Recent Findings

Although a considerable amount of research has been published on this topic and in general on fluid management in acute illness, the quality of the evidence tends to vary. Intravascular volume management should aim for euvolemia. There is evidence of harm with aggressive administration of fluid aimed at achieving hypervolemia in cases of subarachnoid hemorrhage. Isotonic crystalloids should be the preferred agents for volume replacement, while colloids, glucose-containing hypotonic solutions, and other hypotonic solutions or albumin should be avoided. Osmotherapy seems to be effective in intracranial hypertension management; however, there is no clear evidence regarding the superiority of hypertonic saline over mannitol.


Fluid therapy plays an important role in the management of acute brain injury patients. However, fluids are a double-edged weapon because of the potential risk of hyper-hydration, hypo- or hyper-osmolar conditions, which may unfavorably affect the clinical course and the outcome.


Fluid therapy Brain injury Subarachnoid hemorrhage Mannitol Hypertonic saline 


Compliance with Ethical Standards

Conflict of Interest

Sandra Rossi, Edoardo Picetti, Tommaso Zoerle, Marco Carbonara, Elisa R Zanier and Nino Stocchetti each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Finfer S, Myburgh JA, Bellomo R. Intravenous fluid therapy in the critically ill adult. Nat Rev Nephrol. 2018;14(9):541–57.CrossRefPubMedGoogle Scholar
  2. 2.
    • van der Jagt M. Fluid management of the neurological patient: a concise review. Crit Care. 2016;20(1):126. A concise review with clear cartoons exemplifying water movements and the main goals of fluid therapy in ABI CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Benabid AL, Baud A, de Rougemont J, Faccioli F, Barge M, Chirossel JP. Drastic dehydration as treatment of intracranial hypertension in severe head injuries. In: Shulman K, Marmarou A, Miller JD, Becker DP, Hochwald GM, Brock M, editors. Intracranial Pressure IV. Springer-Verlag: Berlin Heidelberg; 1980. p. 88–9.CrossRefGoogle Scholar
  4. 4.
    Garretson HD, Mcgraw CP, O’Connor C, Howard G, Shields CB, Roski R. Effectiveness of fluid restriction, mannitol and furosemide in reducing ICP. In: Ishii S, Nagai H, Brock M, editors. Intracranial pressure. Berlin: Springer Verlag; 1983. p. 742–5.CrossRefGoogle Scholar
  5. 5.
    • Hladky SB, Barrand MA. Mechanisms of fluid movement into, through and out of the brain: evaluation of the evidence. Fluids Barriers CNS. 2014;11(1):26. A comprehensive review of the mechanisms involved in fluid distribution in the CNS CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    • Hladky SB, Barrand MA. Fluid and ion transfer across the blood-brain and blood-cerebrospinal fluid barriers; a comparative account of mechanisms and roles. Fluids Barriers CNS. 2016;13(1):–19. A comprehensive review of the mechanisms involved in fluid distribution in the CNS Google Scholar
  7. 7.
    Myburgh J. Patient-centered outcomes and resuscitation fluids. N Engl J Med. 2018;378(9):862–3.CrossRefPubMedGoogle Scholar
  8. 8.
    •• Oddo M, Poole D, Helbok R, Meyfroidt G, Stocchetti N, Bouzat P, et al. Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations. Intensive Care Med. 2018;44(4):449–63. A clinical review of the literature with practical recommendations on three main topics: general fluid management (volume resuscitation and maintenance), hyperosmolar fluids for ICP control, fluid therapy for the management of DCI CrossRefPubMedGoogle Scholar
  9. 9.
    Levick JR, Michel CC. Microvascular fluid exchange and the revised Starling principle. Cardiovasc Res. 2010;87(2):198–210.CrossRefPubMedGoogle Scholar
  10. 10.
    Sun BL, Wang LH, Yang T, Sun JY, Mao LL, Yang MF, Yuan H, Colvin RA, Yang XY Lymphatic drainage system of the brain: a novel target for intervention of neurological diseases. Prog Neurobiol 2018; 163–164: 118–143.CrossRefPubMedGoogle Scholar
  11. 11.
    Qureshi AI, Suarez JI. Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension. Crit Care Med. 2000;28(9):3301–13.CrossRefPubMedGoogle Scholar
  12. 12.
    Vagnerova K, Rusa R. Fluid management during craniotomy. In: Cottrell JE, Patel P, editors. Neuroanesthesia. Elsevier; 2016. pp. 152–165.Google Scholar
  13. 13.
    Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med. 2000;342(21):1581–9.CrossRefGoogle Scholar
  14. 14.
    Adrogué HJ, Madias NE. Hypernatremia. N Engl J Med. 2000;342(20):1493–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Berlin DA, Bakker J. Understanding venous return. Intensive Care Med. 2014;40(10):1564–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Berlin DA, Bakker J. Starling curves and central venous pressure. Crit Care. 2015;19:55.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Marmarou A, Andesron RL, Waed JD, Choi SC, Young HF, Eisenberg HM, et al. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg. 1991;75:S59–66.Google Scholar
  18. 18.
    Jones PA, Andrews PJ, Midgley S, Anderson SI, Piper IR, Tocher JL, et al. Measuring the burden of secondary insults in head-injured patients during intensive care. J Neurosurg Anesthesiol. 1994;6(1):4–14.CrossRefPubMedGoogle Scholar
  19. 19.
    Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg. 2000;92(1):1–6.CrossRefPubMedGoogle Scholar
  20. 20.
    McHugh GS, Engel DC, Butcher I, Steyerberg EW, Lu J, Mushkudiani N, et al. Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24(2):287–93.CrossRefPubMedGoogle Scholar
  21. 21.
    Güiza F, Depreitere B, Piper I, Citerio G, Chambers I, Jones PA, et al. Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury. Intensive Care Med. 2015;41(6):1067–76.CrossRefPubMedGoogle Scholar
  22. 22.
    Güiza F, Meyfroidt G, Piper I, Citerio G, Chambers I, Enblad P, et al. Cerebral perfusion pressure insults and associations with outcome in adult traumatic brain injury. J Neurotrauma. 2017;34(16):2425–31.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017;16(12):987–1048.CrossRefPubMedGoogle Scholar
  24. 24.
    Maroon JC, Nelson PB. Hypovolemia in patients with subarachnoid hemorrhage: therapeutic implications. Neurosurgery. 1979;4(3):223–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Nelson PB, Seif SM, Maroon JC, Robinson AG. Hyponatremia in intracranial disease: perhaps not the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Neurosurg. 1981;55(6):938–41.CrossRefPubMedGoogle Scholar
  26. 26.
    Solomon RA, Post KD, McMurtry JG 3rd. Depression of circulating blood volume in patients after subarachnoid hemorrhage: implications for the management of symptomatic vasospasm. Neurosurgery. 1984;15(3):354–61.CrossRefPubMedGoogle Scholar
  27. 27.
    Kassell NF, Peerless SJ, Durward QJ, Beck DW, Drake CG, Adams HP. Treatment of ischemic deficits from vasospasm with intravascular volume expansion and induced arterial hypertension. Neurosurgery. 1982;11(3):337–43.CrossRefPubMedGoogle Scholar
  28. 28.
    • de Oliveira Manoel AL, Goffi A, Zampieri FG, Turkel-Parrella D, Duggal A, Marotta TR, et al. The critical care management of spontaneous intracranial hemorrhage: a contemporary review. Crit Care. 2016;20:272. A concise review of the management of severe SAH patients, including fluid strategies CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Muench E, Horn P, Bauhuf C, Roth H, Philipps M, Hermann P, et al. Effects of hypervolemia and hypertension on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation after subarachnoid hemorrhage. Crit Care Med. 2007;35(8):1844–51.CrossRefPubMedGoogle Scholar
  30. 30.
    SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, George Institute for International Health, Myburgh J, Cooper DJ, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007;357(9):874–84.CrossRefGoogle Scholar
  31. 31.
    Cooper DJ, Myburgh J, Heritier S, Finfer S, Bellomo R, Billot L, et al. Albumin resuscitation for traumatic brain injury: is intracranial hypertension the cause of increased mortality? J Neurotrauma. 2013;30(7):512–8.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012;367(2):124–34.CrossRefPubMedGoogle Scholar
  33. 33.
    Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367(20):1901–11.CrossRefPubMedGoogle Scholar
  34. 34.
    Morgan TJ, Venkatesh B, Hall J. Crystalloid strong ion difference determines metabolic acid-base change during acute normovolaemic haemodilution. Intensive Care Med. 2004;30(7):1432–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Kellum JA, Song M, Li J. Science review: extracellular acidosis and the immune response: clinical and physiologic implications. Crit Care. 2004;8(5):331–6.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Hadimioglu N, Saadawy I, Saglam T, Ertug Z, Dinckan A. The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation. Anesth Analg. 2008;107(1):264–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Handy JM, Soni N. Physiological effects of hyperchloraemia and acidosis. Br J Anaesth. 2008;101(2):141–50.CrossRefPubMedGoogle Scholar
  38. 38.
    Cooper DJ, Myles PS, McDermott FT, Murray LJ, Laidlaw J, Cooper G, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA. 2004;291(11):1350–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829–39.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564–75.CrossRefGoogle Scholar
  41. 41.
    Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009;136(1):102–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39(2):259–65.CrossRefPubMedGoogle Scholar
  43. 43.
    Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS. Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg. 2001;95(4):560–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Kissoon NR, Mandrekar JN, Fugate JE, Lanzino G, Wijdicks EF, Rabinstein AA. Positive fluid balance is associated with poor outcomes in subarachnoid hemorrhage. J Stroke Cerebrovasc Dis. 2015;24(10):2245–51.CrossRefPubMedGoogle Scholar
  45. 45.
    Ropper AH. Hyperosmolar therapy for raised intracranial pressure. N Engl J Med. 2012;367(8):746–52.CrossRefPubMedGoogle Scholar
  46. 46.
    Khanna S, Davis D, Peterson B, Fisher B, Tung H, O’Quigley J, et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med. 2000;28(4):1144–51.CrossRefPubMedGoogle Scholar
  47. 47.
    Bouzat P, Oddo M. Lactate and the injured brain: friend or foe? Curr Opin Crit Care. 2014;20(2):133–40.CrossRefPubMedGoogle Scholar
  48. 48.
    Gordon GR, Choi HB, Rungta RL, Ellis-Davies GC, MacVicar BA. Brain metabolism dictates the polarity of astrocyte control over arterioles. Nature. 2008;456(7223):745–9.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Berthet C, Lei H, Thevenet J, Gruetter R, Magistretti PJ, Hirt L. Neuroprotective role of lactate after cerebral ischemia. J Cereb Blood Flow Metab. 2009;29(11):1780–9.CrossRefPubMedGoogle Scholar
  50. 50.
    Quintard H, Patet C, Zerlauth JB, Suys T, Bouzat P, Pellerin L, et al. Improvement of neuroenergetics by hypertonic lactate therapy in patients with traumatic brain injury is dependent on baseline cerebral lactate/pyruvate ratio. J Neurotrauma. 2016;33(7):681–7.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Ichai C, Armando G, Orban JC, Berthier F, Rami L, Samat-Long C, et al. Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain-injured patients. Intensive Care Med. 2009;35(3):471–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Ichai C, Payen JF, Orban JC, Quintard H, Roth H, Legrand R, et al. Half-molar sodium lactate infusion to prevent intracranial hypertensive episodes in severe traumatic brain injured patients: a randomized controlled trial. Intensive Care Med. 2013;39(8):1413–22.CrossRefPubMedGoogle Scholar
  53. 53.
    Italian Acute Stroke Study Group. Haemodilution in acute stroke: results of the Italian haemodilution trial. Lancet. 1988;1(8581):318–21.Google Scholar
  54. 54.
    Ginsberg MD, Palesch YY, Hill MD, Martin RH, Moy CS, Barsan WG, et al. High-dose albumin treatment for acute ischaemic stroke (ALIAS) part 2: a randomised, double-blind, phase 3, placebo-controlled trial. Lancet Neurol. 2013;12(11):1049–58.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Lennihan L, Mayer SA, Fink ME, Beckford A, Paik MC, Zhang H, et al. Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage: a randomized controlled trial. Stroke. 2000;31(2):383–91.CrossRefPubMedGoogle Scholar
  56. 56.
    Mutoh T, Kazumata K, Terasaka S, Taki Y, Suzuki A, Ishikawa T. Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage. Stroke. 2014;45(5):1280–4.CrossRefPubMedGoogle Scholar
  57. 57.
    Baker AJ, Rhind SG, Morrison LJ, Black S, Crnko NT, Shek PN, et al. Resuscitation with hypertonic saline-dextran reduces serum biomarker levels and correlates with outcome in severe traumatic brain injury patients. J Neurotrauma. 2009;26(8):1227–40.CrossRefPubMedGoogle Scholar
  58. 58.
    Cottenceau V, Masson F, Mahamid E, Petit L, Shik V, Sztark F, et al. Comparison of effects of equiosmolar doses of mannitol and hypertonic saline on cerebral blood flow and metabolism in traumatic brain injury. J Neurotrauma. 2011;28(10):2003–12.CrossRefPubMedGoogle Scholar
  59. 59.
    Jagannatha AT, Sriganesh K, Devi BI, Rao GS. An equiosmolar study on early intracranial physiology and long-term outcome in severe traumatic brain injury comparing mannitol and hypertonic saline. J Clin Neurosci. 2016;27:68–73.CrossRefPubMedGoogle Scholar
  60. 60.
    Diringer MN, Bleck TP, Claude Hemphill J 3rd, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211–40.CrossRefGoogle Scholar
  61. 61.
    Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711–37.CrossRefPubMedGoogle Scholar
  62. 62.
    Le Roux P, Menon DK, Citerio G, Vespa P, Bader MK, Brophy GM, et al. Consensus summary statement of the international multidisciplinary consensus conference on multimodality monitoring in neurocritical care: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Neurocrit Care. 2014;21(Suppl 2):S1–26.CrossRefPubMedGoogle Scholar
  63. 63.
    Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e110.CrossRefPubMedGoogle Scholar
  64. 64.
    Diringer MN. New trends in hyperosmolar therapy? Curr Opin Crit Care. 2013;19(2):77–82.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Gantner D, Moore EM, Cooper DJ. Intravenous fluids in traumatic brain injury: what’s the solution? Curr Opin Crit Care. 2014;20(4):385–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Sandra Rossi
    • 1
    Email author
  • Edoardo Picetti
    • 1
  • Tommaso Zoerle
    • 2
  • Marco Carbonara
    • 2
  • Elisa R Zanier
    • 3
  • Nino Stocchetti
    • 2
    • 4
  1. 1.Department of Anesthesia and Intensive CareAzienda Ospedaliero-Universitaria di ParmaParmaItaly
  2. 2.Neuro ICUFondazione IRCCS Cà Granda Ospedale Maggiore PoliclinicoMilanItaly
  3. 3.Department of Neuroscience, Laboratory of Acute Brain Injury and Therapeutic StrategiesIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
  4. 4.Department of Physiopathology and TransplantationMilan UniversityMilanItaly

Personalised recommendations