Effects of Hypertonic Lactate Solutions on Intracranial Dynamics, Cerebral Oxygenation, and Metabolism in Patients with Acute Brain Injury: A Scoping Review.

Hyperosmolar therapies remain a cornerstone in the management of intracranial hypertension in patients with acute brain injury (ABI). Beyond their osmotic properties, hypertonic lactate solutions have recently gained interest as a potential therapeutic strategy capable of influencing not only intracranial dynamics but also cerebral metabolism and systemic physiology. However, the extent and consistency of these physiological effects in human studies remain incompletely characterized. To map and synthesize the available clinical evidence evaluating the effects of hypertonic lactate solutions on intracranial dynamics, cerebral oxygenation, cerebral metabolism, and systemic physiology in adult patients with ABI. A scoping review was conducted following Joanna Briggs Institute methodological guidance and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension. Systematic searches were performed in PubMed, Embase, Scopus, and Web of Science. Two reviewers independently screened studies and extracted data using a standardized charting form. Twelve studies published between 2009 and 2025 were included. Across studies, hypertonic lactate administration was consistently associated with reductions in intracranial pressure (ICP) while preserving cerebral perfusion pressure. Several investigations also reported physiological signals suggesting modulation of cerebral metabolism, including increases in cerebral microdialysis lactate and glucose concentrations and potential improvements in markers of oxidative metabolism. Systemic effects were generally predictable and well tolerated, including moderate increases in arterial lactate, sodium, and alkalinizing metabolic shifts within clinically acceptable ranges. Hypertonic lactate appears to act as a physiologically integrated therapy combining osmotic control of ICP with potential metabolic and systemic effects. Although current human evidence suggests promising physiological benefits, what is ultimately required is a large-scale, adequately powered clinical trial incorporating clinically relevant outcome biomarkers, including functional neurological recovery, quality of life measures, and validated biomarkers of neuronal injury to determine whether these physiological benefits translate into meaningful patient benefit.