What is the management of intracranial hypertension?

From the Guidelines

Management of intracranial hypertension should start with elevating the head of the bed to 30 degrees and using hyperosmolar therapy with either mannitol or hypertonic saline, as recommended by the most recent and highest quality study 1. The initial management of intracranial hypertension includes basic measures such as:

• Elevating the head of the bed to 30 degrees to promote venous drainage
• Maintaining adequate oxygenation
• Avoiding factors that increase intracranial pressure such as pain, agitation, and fever Hyperosmolar therapy is a cornerstone treatment, with mannitol (0.5-1 g/kg IV) or hypertonic saline (3% solution at 5 ml/kg i.v. over 15 mins) being first-line medications, as supported by 1. Sedation with propofol or midazolam helps reduce cerebral metabolic demands. If these measures fail, temporary hyperventilation to a PaCO2 of 30-35 mmHg can provide rapid but short-term relief. For refractory cases, more aggressive interventions include barbiturate coma, decompressive craniectomy, or CSF drainage via an external ventricular drain. Throughout treatment, continuous ICP monitoring is essential, with a goal to maintain ICP below 20-22 mmHg and cerebral perfusion pressure above 60 mmHg, as recommended by 1 and 1. These interventions work by reducing cerebral blood volume, decreasing cerebral edema, or creating space for the swollen brain, ultimately preventing secondary brain injury from inadequate perfusion and herniation. Key considerations in the management of intracranial hypertension include:
• Monitoring fluid, sodium, and chloride balances when using osmotic agents
• Avoiding prophylactic administration of hypertonic saline solution in patients with no evidence of intracranial hypertension
• Being aware of the potential side effects of osmotic agents, such as mannitol-induced osmotic diuresis and hypertonic saline-induced hypernatremia and hyperchloremia.

From the FDA Drug Label

Reduction of intracranial pressure and brain mass. In adults a dose of 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes; pediatric patients 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area over a period of 30 to 60 minutes.

The management of intracranial hypertension involves the administration of mannitol (IV) at a dose of 0.25 to 2 g/kg body weight as a 15% to 25% solution over a period of 30 to 60 minutes in adults, and 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area over a period of 30 to 60 minutes in pediatric patients 2.

• Key considerations:
  • Careful evaluation of circulatory and renal reserve prior to and during administration
  • Monitoring of fluid and electrolyte balance, body weight, and total input and output before and after infusion
  • Evidence of reduced cerebral spinal fluid pressure must be observed within 15 minutes after starting infusion 2.
• Mechanism of action: Mannitol exerts its osmotic diuretic effect by increasing the osmotic pressure of plasma and the extracellular space, inducing the movement of intracellular water to the extracellular and vascular spaces, which underlies its role in reducing intracranial pressure 2.

From the Research

Management of Intracranial Hypertension

The management of intracranial hypertension involves several strategies to reduce increased intracranial pressure. Key aspects include:

• Meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure 3, 4
• Ruling out new mass lesions that should be surgically evacuated when intracranial pressure becomes elevated 3, 4
• Medical management of increased intracranial pressure, which should include:
  • Sedation 3, 4
  • Drainage of cerebrospinal fluid 3, 4
  • Osmotherapy with either mannitol or hypertonic saline 3, 4
• For intracranial hypertension refractory to initial medical management, consideration of:
  • Barbiturate coma 3, 4
  • Hypothermia 5
  • Decompressive craniectomy 3, 4, 5

Specific Considerations

• Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury 3, 4
• For idiopathic intracranial hypertension, weight reduction and acetazolamide may be considered as treatment strategies 6
• Surgical options, such as optic nerve sheath fenestration or cerebrospinal fluid diversion surgery, may be considered in certain cases 6

Therapeutic Approaches

• Therapeutic hypothermia has been studied as a potential treatment for intracranial hypertension, with some evidence suggesting it may be effective in reducing intracranial pressure 5
• Comparison of therapeutic hypothermia to other treatments, such as hypertonic saline, lumbar CSF drainage, and decompressive craniectomy, suggests that it may have a favorable risk/benefit profile 5