From the Guidelines
Intracranial hypertension should be managed with a balanced approach, starting with simple measures such as head positioning, analgesia, and sedation, and progressing to more aggressive measures as clinically indicated, with careful monitoring of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in a critical care unit. The management of intracranial hypertension is complex and requires a multifaceted approach. According to the guidelines from the American Heart Association/American Stroke Association Stroke Council, high blood pressure research council, and the quality of care and outcomes in research interdisciplinary working group 1, there is no single best approach to managing intracranial hypertension, and treatment should be individualized based on the patient's specific needs and clinical presentation.
Some key considerations in the management of intracranial hypertension include:
- Maintaining a CPP of 70 mm Hg to minimize reflex vasodilation or ischemia
- Using osmotic agents such as mannitol to reduce ICP
- Considering the use of hypertonic saline, which has been shown to reduce ICP in some studies 1
- Avoiding nonselective hyperventilation, which can enhance secondary brain injury
- Monitoring for potential complications of treatment, such as renal failure, rebound intracranial hypertension, and cardiovascular depression
It is essential to note that the exact frequency of increased ICP in patients with intracerebral hemorrhage (ICH) is not known, and many patients with smaller ICHs may not require measures to decrease ICP. However, for those patients with clinical evidence of increased ICP, a balanced approach to management is crucial to prevent further brain injury and improve outcomes. Regular monitoring of ICP and CPP, as well as clinical assessment, is necessary to guide treatment and adjust the management plan as needed.
From the Research
Definition and Management of Intracranial Hypertension
- Intracranial hypertension is a medical emergency requiring prompt diagnosis and management, as it can lead to severe debilitating or fatal disease processes 2.
- The maintenance of normal intracranial pressure and cerebral perfusion pressure is the central focus of management to prevent secondary brain injury 3.
Treatment Options for Intracranial Hypertension
- Hyperosmolar therapy, including mannitol or hypertonic saline, represents the cornerstone of medical treatment of acute intracranial hypertension 3, 4.
- Hypertonic saline has been shown to have a more sustained effect on intracranial pressure and can effectively increase cerebral perfusion pressure compared to mannitol 5.
- However, there is insufficient evidence to support a formal recommendation on the use of any specific hyperosmolar medication in patients with acute increased intracranial pressure 6.
General Prophylactic Measures and Surgical Interventions
- 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 3.
- Surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering intracranial pressure based on specific indications and conditions 3.
Monitoring and Individualized Therapeutic Strategies
- Monitoring of intracranial pressure and cerebral perfusion pressure is crucial in the management of intracranial hypertension 3.
- Individualization of specific therapeutic modalities is emphasized to optimize the clinical outcome, and the therapeutic strategy should be based on a staircase approach 2, 3.