What is the treatment for Intracranial Hypertension (Increased Intracranial Pressure)?

From the Guidelines

Treatment of intracranial hypertension requires a stepwise approach targeting the underlying cause while reducing intracranial pressure, with the most recent and highest quality study recommending the use of mannitol 20% or hypertonic saline solution at a dose of 250 mOsm in infusion of 15–20 minutes to treat threatened intracranial hypertension or signs of brain herniation after controlling secondary brain insults 1.

Key Considerations

• The management of intracranial hypertension involves a balanced approach, starting with simple and less aggressive measures such as head positioning, analgesia, and sedation, and progressing to more aggressive measures as clinically indicated 1.
• Hyperosmolar therapy with mannitol or hypertonic saline can rapidly reduce intracranial pressure, but the choice of agent and dosing should be individualized based on the patient's specific needs and clinical response 1.
• Corticosteroids like dexamethasone may be used to reduce edema, particularly with mass lesions, but their use should be carefully considered and monitored due to potential side effects 1.

Treatment Options

• First-line medical management:
  • Mannitol 20% or hypertonic saline solution at a dose of 250 mOsm in infusion of 15–20 minutes 1
  • Acetazolamide (starting at 500mg twice daily, increasing to 1000-2000mg daily if needed) to reduce cerebrospinal fluid production
  • Topiramate (25-50mg daily, titrating up to 100-200mg daily) as an alternative or adjunct to acetazolamide
  • Furosemide (20-40mg daily) as a second-line diuretic
• Surgical interventions:
  • CSF shunting procedures (ventriculoperitoneal or lumboperitoneal shunts)
  • Optic nerve sheath fenestration

Monitoring and Follow-up

• Regular ophthalmologic monitoring is crucial to assess for papilledema resolution and prevent permanent vision loss, which is the most serious complication of untreated intracranial hypertension.
• Frequent neurological assessments must be done to look for potential changes in brain perfusion and to adjust treatment as needed.

From the FDA Drug Label

1 INDICATIONS & USAGE Mannitol Injection is indicated for the following purposes in adults and pediatric patients. Therapeutic Use Reduction of intracranial pressure and brain mass.

12 CLINICAL PHARMACOLOGY 12. 1 Mechanism of Action ... By increasing the osmotic pressure of plasma and the extracellular space, intravenously administered mannitol will induce the movement of intracellular water to the extracellular and vascular spaces. This action underlies the role of mannitol in reducing intracranial pressure, intracranial edema, and intraocular pressure.

Intracranial Hypertension Treatment: Mannitol (IV) is indicated for the reduction of intracranial pressure and brain mass 2. It works by increasing the osmotic pressure of plasma and the extracellular space, which induces the movement of intracellular water to the extracellular and vascular spaces, thereby reducing intracranial pressure and edema 2.

• Key Points:
  • Mannitol (IV) is used to reduce intracranial pressure
  • It is indicated for therapeutic use in adults and pediatric patients
  • The mechanism of action involves increasing osmotic pressure to reduce intracranial edema 2

From the Research

Treatment Options for Intracranial Hypertension

• Surgical treatment is indicated when intracranial hypertension is caused by hematoma, contusion, tumor, hygroma, hydrocephalus, or pneumatocephalus 3
• Medical options for treating elevated ICP include head of bed elevation, IV mannitol, hypertonic saline, transient hyperventilation, and barbiturates 4
• Hyperosmolar therapy (mannitol or hypertonic saline) represents the cornerstone of medical treatment of acute intracranial hypertension 5
• Hypertonic saline may be more effective than mannitol in reducing intracranial pressure, but there is no clear benefit in regards to long-term neurologic outcome 6

Management Strategies

• General prophylactic measures such as patient's head elevation, fever control, adequate analgesia, and sedation depth should be applied immediately to all patients with suspected intracranial hypertension 5
• Surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering ICP 5
• Therapies aimed directly at keeping ICP <20 mmHg have resulted in improved survival and neurological outcome 7
• Cerebral perfusion pressure targeted therapy may offer better outcome than ICP targeted therapies 7

Refractory Cases

• Barbiturate coma, moderate hypothermia, and surgical decompression may be helpful in refractory cases 7
• High-dose barbiturate administration and decompressive craniectomy as a last step are recommended for controlling elevated ICP refractory to maximum standard medical and surgical treatment 5