What is the treatment for a patient with a seizure and increased intracranial pressure?

From the Guidelines

The treatment for a patient with seizures and increased intracranial pressure (ICP) requires immediate management of both conditions simultaneously, prioritizing securing the airway, ensuring adequate oxygenation, and controlling seizures with benzodiazepines and antiepileptic drugs, while also reducing ICP through hyperosmolar therapy, hyperventilation, and maintaining cerebral perfusion pressure (CPP) ≥ 60 mmHg, as recommended by the most recent guidelines 1.

Key Considerations

• Securing the airway and ensuring adequate oxygenation is crucial in the initial management of a patient with seizures and increased ICP.
• For seizure control, administering benzodiazepines such as intravenous lorazepam (2-4 mg) or diazepam (5-10 mg), followed by antiepileptic drugs like levetiracetam (loading dose 20-60 mg/kg) or phenytoin (loading dose 15-20 mg/kg at ≤50 mg/min) for maintenance therapy, is essential.
• To reduce ICP, elevating the head of the bed to 30 degrees, maintaining normothermia, and considering hyperosmolar therapy with mannitol (0.5-1 g/kg IV) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) are recommended.
• Hyperventilation to a PaCO2 of 30-35 mmHg may provide temporary relief in emergencies, and sedation with propofol (starting at 5 mcg/kg/min) or midazolam may be necessary.
• Continuous EEG monitoring and ICP monitoring are crucial for guiding therapy, as seizures can worsen ICP through increased cerebral blood flow and metabolic demands, while elevated ICP can trigger or exacerbate seizure activity.

Management Approach

• The management approach should be stepwise, reserving more aggressive interventions for situations when no response is observed, and individualizing CPP based on neuromonitoring data and the cerebral autoregulation status of the individual patient 1.
• Maintaining a CPP ≥ 60 mmHg is recommended when ICP monitoring becomes available, and this value should be adjusted based on neuromonitoring data and the cerebral autoregulation status of the individual patient.
• The use of osmotherapy and/or hypocapnia may be recommended in cases of cerebral herniation, awaiting or during emergency neurosurgery 1.

Guiding Principles

• The guiding principles for managing a patient with seizures and increased ICP should prioritize reducing ICP, controlling seizures, and maintaining adequate cerebral perfusion, as outlined in the most recent guidelines 1.
• The treatment approach should be tailored to the individual patient's needs, taking into account their underlying medical conditions, the severity of their seizures and increased ICP, and their response to initial management.
• Close monitoring and frequent reassessment are essential to ensure that the treatment approach is effective and to make adjustments as needed.

From the FDA Drug Label

When propofol injectable emulsion is used in patients with increased intracranial pressure or impaired cerebral circulation, significant decreases in mean arterial pressure should be avoided because of the resultant decreases in cerebral perfusion pressure To avoid significant hypotension and decreases in cerebral perfusion pressure, an infusion or slow bolus of approximately 20 mg every 10 seconds should be utilized instead of rapid, more frequent, and/or larger boluses of propofol injectable emulsion. Slower induction, titrated to clinical responses, will generally result in reduced induction dosage requirements (1 mg/kg to 2 mg/kg) When increased ICP is suspected, hyperventilation and hypocarbia should accompany the administration of propofol injectable emulsion

The treatment for a patient with a seizure and increased intracranial pressure involves administering propofol injectable emulsion in a way that avoids significant decreases in mean arterial pressure, which can decrease cerebral perfusion pressure.

• Infusion rate: Use an infusion or slow bolus of approximately 20 mg every 10 seconds.
• Induction dosage: Slower induction with a reduced dosage requirement of 1 mg/kg to 2 mg/kg.
• Hyperventilation and hypocarbia: Accompany the administration of propofol injectable emulsion with hyperventilation and hypocarbia when increased ICP is suspected. This approach is based on the information provided in the drug label for propofol injectable emulsion 2.

From the Research

Treatment Overview

The treatment for a patient with a seizure and increased intracranial pressure involves a combination of medical and surgical options. The primary goal is to reduce intracranial pressure (ICP) and prevent further brain damage.

Medical Options

• Head of bed elevation to reduce ICP 3
• Administration of IV mannitol or hypertonic saline to reduce ICP 3, 4, 5
• Transient hyperventilation to reduce ICP 3
• Use of barbiturates to reduce ICP 3, 5
• Sedation, endotracheal intubation, mechanical ventilation, and neuromuscular paralysis may be necessary in refractory cases 3
• Seizure prophylaxis with medications such as levetiracetam or phenytoin may be considered, although the effectiveness of levetiracetam in reaching therapeutic levels in the cerebrospinal fluid (CSF) is uncertain 6

Surgical Options

• CSF drainage through an external ventricular catheter if hydrocephalus is present 3
• Decompression of a surgical lesion, such as an intracranial hematoma or tumor, if the patient's condition is deemed salvageable 3

Monitoring and Management

• Continuous monitoring of ICP, arterial blood pressure, and cerebral perfusion pressure is crucial in managing patients with increased ICP 3, 4, 5
• Automated data collection can provide a more accurate assessment of patient status and responsiveness to treatment 5
• The relationship between changes in ICP and incidence of subclinical seizures is not fully understood, and further research is needed to determine the optimal treatment strategy 7