| Background: Cerebral infarction is a common desease with high mortality and morbidity. And the brain edema is a major cause of early death after cerebral infarction. So management of reducing brain edema and controling elevated intracranial pressure (ICP) of these patients is currently being changed to an earlier and more aggressive treatment regimen. Mannitol, glycerin fructose, furosemide and sodium aescinate are claimed to reduce brain oedema and are widely used clinically, but the efficacy and safety of them used in acute ischemic stroke are not clear.Objectives: To test the efficacy and safety of the treatment with mannitol, glycerin fructose, furosemide or sodium aescinate after acute ischaemic stroke.Methods: The standard search strategy was made according to the Cochrane systematic review handbook and the trails were searched in the databank MEDLINE, EMBASE, VIP, CBM and so on. The Chinese Journal of Neurology and Journal of Clinical Neurology were also checked. Then study selection was performed base on included and excluded criterion. Two of the reviewers independently extracted data from the trials. Data synthesis and analysis was performed with the use of the Cochrane Review Manager software (RevMan version 5.0).Results: Mannitol for acute cerebral infarction, 742 studies were searched and 8 RCTs involving 689 participants were eligible according to included and excluded criterions. All the trials were assessed of poor methodological quality. Case fatality, the proportion of dependent patients at the end of the follow-up were not reported. Pooled analysis of 5 trials showed mannitol was associated with a significant improvement of the neurological deficit (RR= 1.20, 95%CI 1.10-1.32 for the dichotomous data ; MD=-4.64, 95%CI-6.55~-2.73 for the continuous data ) . But another trail showed no difference between mannitol-treated and control groups in improving the neurological deficit (RR=0.98,95%CI 0.52~1.83).2 trials evaluated the improvement of the neurological symptom and signs. The pooled analysis indicated that there is no difference for mannitol in improving neurological symptom and signs after cerebral infarction between mannitol-treated and control groups.6 trials reported the side effects and 4 of which showed no appearance of side effects.2 trial reported that the patients who were treated with mannitol have complications of electrolytes disturbance(17.5%), heart failure(5%), renal failure(10%), aggravation of cerebral edema (5%)and rebound phenomenon(32.5%). Hyponatremia was reported in the other trial with the incident rate 13.3%.Glycerin fructose for acute cerebral infarction: 66 studies were searched and no trials were eligible.Furosemide for acute cerebral infarction: 67 studies were searched and no trials were eligible.Sodium aescinate for acute cerebral infarction:1 trial involving 116 participants was included and the analysis showed that sodium aescinate have positive effect in improving the neurological deficit(X2=8.39,P<0.05),but the case fatality, the proportion of dependent patients, and side effects were not reported.Conclusions: (1) This systematic review suggests a favourable effect of mannitol treatment on the improvement of neurological deficit after cerebral infarction, but the methodological quality was poor and the number of patients is relatively small. In addition, the evidence of benefit in long term survival and dependency are not supported. So the efficacy and safety of mannitol treatment in cerebral infarction have not been yet confirmed. (2) As a result of lack of appropriate randomized trials, currently no conclusion can be drawn on the effects and safety of glycerin fructose and furosemide in acute cerebral infarction.(3) The effect of sodium aescinate on improvement of neurological deficit after cerebral infarction is uncertain. (4) To prove the efficacy and safety of mannitol, glycerin fructose , furosemide and sodium aescinate, placebo-controlled, unconfounded, properly randomized clinical studies should be designed and performed.
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