The Moscote-Janjua-Agrawal Rebound Risk Score: A Pragmatic Tool for Predicting Intracranial Hypertension Recurrence After Osmotherapy

Rebound intracranial hypertension (RIH) is an underdiagnosed but serious complication of hyperosmolar therapy in patients with acute brain injury.[1] Despite the need for osmotherapy with mannitol or hypertonic saline (HTS) for intracranial pressure (ICP) control, no consensus approach to identifying high-risk patients has developed.[1] [2] Osmotherapy using agents like mannitol or HTS continues to be an integral part in managing increased ICP in conditions such as traumatic brain injury, subarachnoid hemorrhage, and large-vessel stroke.[3] [4] [5] Useful as they are, sudden cessation or inappropriately rapid tapering of these agents results in RIH—a potentially life-threatening condition with ICP overshoot above its pretreatment baseline.[6] Although clinically important, RIH is little understood and underutilized at the bedside. Therapeutic tapering or extension is often achieved on empirical basis.[7] This short article suggests the following systematic approach to risk stratification of rebound through development of a Moscote-Janjua-Agrawal Rebound Risk Score (MJA-RIH) that condenses clinical and biochemical markers into a bedside instrument.

The Pathophysiologic Pathway of Why Rebound Happens

Hyperosmolar therapy creates an osmotic gradient for efflux of water out of brain parenchyma and, consequently, lowers ICP. With time, however, chronic exposure to hyperosmolar agents can induce: (1) iatrogenic dehydration, (2) renal adaptation and sodium retention, (3) re-equilibration of osmotically active material across the blood–brain barrier, (4) intracellular idiogenic osmoles that reverse the osmotic gradient on stopping therapy, and (5) when taper is overly aggressive or thresholds are not watched, ICP breaks due to increased cerebral edema, loss of adaptation, or cerebrospinal fluid (CSF) mismanagement.

 

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The Clinical Problem

RIH is most frequent in: Patients on mannitol > 72 hours, patients with deranged CSF dynamics (ventriculostomy, craniectomy, open skull fracture), patients with elevated serum sodium or osmolality at taper time, and those receiving repeated boluses without surveillance of ICP. On the other hand, variability in intensive care unit practice patterns aggravates the issue. We propose the Moscote-Janjua-Agrawal Rebound Risk Score as a clinical tool to standardize evaluation and direct tapering of osmotherapy.

 

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Current Hypothesis

We aim to create a new, pragmatic, and clinically useful rebound risk score (MJA-RIH) to identify patients at risk of rebound ICP increase during the discontinuation or tapering of osmotherapy ([Tables 1] and [2]). Synthesis of risk factors guided by up-to-date literature and expert opinion. Risk items were chosen by biological plausibility, published data, and bedside usability. A prototype scoring system is defined.

Table 1 The rebound risk score (RRS): variables and rationale

Component	Criteria	Points	Rationale
1. Duration of osmotherapy	< 48 hour = 0 points; 48–72 hour = 1 point; > 72 hour = 2 points	0–2	Longer exposure leads to osmotic adaptation
2. Frequency of boluses	≤ 1/day = 0; 2/day = 1; ≥ 3/day = 2	0–2	Frequent dosing reflects instability or overtreatment
3. CSF diversion (EVD, lumbar drain)	None = 0; weaned = 1; active drain = 2	0–2	External drainage alters ICP dynamics; premature taper can destabilize
4. Serum sodium at taper	< 145 = 0; 145–150 = 1; > 150 = 2	0–2	High sodium reflects high osmotic load; rapid drop may trigger rebound
5. Brain compliance modifier (decompressive craniectomy, open skull)	No = 0; Yes = 1	0–1	Altered compliance increases risk of silent deterioration
6. Clinical ICP response to last dose	ICP < 20 mm Hg sustained = 0; fluctuating = 1	0–1	Inadequate response predicts recurrence post-withdrawal
Total score range: 0–10

Abbreviations: CSF, cerebrospinal fluid; EVD, external ventricular drain; ICP, intracranial pressure.

Table 2 Risk categories

Score	Risk level	Suggested strategy
0–2	Low	May taper safely with routine monitoring
3–5	Moderate	Taper gradually; monitor serum sodium, ICP closely
6–10	High	Delay taper; consider switch to continuous low-dose HTS or augment with CSF drainage

Abbreviations: CSF, cerebrospinal fluid; HTS, hypertonic saline; ICP, intracranial pressure.

 

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Future Perspective

This proposed score incorporates pathophysiological markers, treatment burden, and patient-specific anatomical considerations to identify patients at risk for rebound ICP. It is simple and bedside-oriented, flexible for both mannitol and HTS regimens, useful for interdisciplinary teams (neurosurgeons, intensivists, pharmacists), though initially conceptual, its components are evidence-informed and aligned with current neurocritical guidelines. Future research should validate the tool through retrospective chart reviews and prospective cohort studies. Regarding the limitations of Moscote-Janjua-Agrawal Rebound Risk Score, it is important to note that this concept needs further studies and to be proved in clinical trials ([Tables 1] and [2]).

The most important outcome predictors of rebound ICP were the duration and frequency of osmotherapy, CSF diversion status, trends in sodium and osmolality, compliance of the brain (i.e., status of craniectomy), and response to therapy early on. A 0 to 10 point rebound risk score is proposed. Finally, rebound ICP is a clinically significant but reversible risk of osmotherapy. The Moscote-Janjua-Agrawal Rebound Risk Score is an evidence-based method for predicting and averting complications upon weaning. It bridges the gap between empirical tapering and individualized neurocritical care.

 

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Conflict of Interest

None declared.

• References

• 1 Parikh SK. Rebound intracranial hypertension. Curr Pain Headache Rep 2024; 28 (05) 395-401
• 2 Asehnoune K, Lasocki S, Seguin P. et al; ATLANREA group, COBI group. Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury - a multicentre prospective cohort study and systematic review. Crit Care 2017; 21 (01) 328
• 3 Freeman N, Welbourne J. Osmotherapy: science and evidence-based practice. BJA Educ 2018; 18 (09) 284-290
• 4 Marko NF. Hypertonic saline, not mannitol, should be considered gold-standard medical therapy for intracranial hypertension. Crit Care 2012; 16 (01) 113
• 5 Ropper AH. Hyperosmolar therapy for raised intracranial pressure. N Engl J Med 2012; 367 (08) 746-752
• 6 Tsui H, Wu S, Kuo H, Chen C. Rebound intracranial hypertension after treatment of spontaneous intracranial hypotension. Eur J Neurol 2006; 13 (07) 780-782
• 7 Moscote-Salazar LR, Janjua TM. Rebound intracranial hypertension during fluid therapy in neurointensive care: a proposal for scheduled discontinuation. Panam J Trauma Crit Care Emerg Surg 2022; 11 (01) 59-60

Publication History

Article published online:
09 August 2025