According to previous Gefitinib reports [11-14,30], in no patient did a severe form of pontine myelinolysis develop. The cases of pontine myelinolysis reported linked to a fast increase in natremia were observed in patients with chronic hyponatremia [16] but not with infusion of HSS for posttraumatic ICH. In a description of HSS infusion in TBI children, no osmotic demyelination syndrome was seen on magnetic resonance imaging, even for natremia reaching 171 mmol/L [12].The main side effect reported in the present report was hyperchloremia. Excessive chloride infusion is a major factor with hyperchloremic acidosis. Thus, it is likely that hyperchloremic acidosis developed in TBI patients treated with continuous HSS infusion. Hyperchloremic acidosis increases the symptoms of postoperative ileus and induces biologic hemostasis perturbation [31].

To date, these complications are not evidence based in the ICU setting.Finally, a dose adaptation of HSS infusion with rigorous biologic monitoring may explain the lack of an uncontrolled metabolic disorder, except for a probable hyperchloremic acidosis, in our results.How to stop the infusion is of major importance to prevent a rebound of ICH, and few data are available. In the study by Qureshi et al. [11], half of the study population experienced a relapse of ICH at the end of the infusion. Interestingly, even with a likely residual barbiturate blood level, we did not report any rebound in ICP after stopping the infusion.

In the current algorithm, the slow tapering of continuous HSS treatment could have restored a normal brain osmolality without inducing a cerebral edema, as the dissipation of accumulated electrolytes and organic osmolytes takes place along with water repletion [6,28,32]. Finally, a slow reduction of the flow may be recommended in case of continuous HSS infusion.Several therapeutics have been tested for decreasing ICP in case of refractory ICH. Despite an improvement of the neurologic recovery in patients with moderate to severe TBI [33], moderate hypothermia may expose patients to intracranial bleeding as well as secondary infections [34] and is not currently recommended in patients with refractory ICH [5]. Surgical craniotomy is another option, but the optimal timing to perform this procedure remains controversial, and its efficiency to enhance neurologic recovery is still debated [18,35]. Regarding the absence of severe side effects with the current protocol, continuous controlled infusion of HSS may thus be an interesting alternative for the treatment of refractory ICH.Our study encountered limitations. First, the study had a retrospective design, and a randomized trial is necessary to confirm these results. Second, the external validity of this Dacomitinib single-center study may be limited.