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. Publication History Article published online: 09 August 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Pvt. Ltd.