What is the treatment for intracranial hypertension?

From the Guidelines

The treatment for intracranial hypertension should focus on a stepwise approach, starting with elevation of the head of bed to 30-45 degrees, maintaining adequate oxygenation, and avoiding neck compression to optimize venous drainage, as these initial measures are crucial in managing increased intracranial pressure. According to the most recent and highest quality study available, which is the European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage published in 2014 1, there is no strong evidence supporting the use of specific interventions like glycerol or mannitol in improving outcomes for patients with intracranial hemorrhage.

Initial Management

• Elevation of the head of bed to 30-45 degrees
• Maintaining adequate oxygenation
• Avoiding neck compression to optimize venous drainage
• Hyperosmolar therapy with mannitol (0.25-1 g/kg IV every 4-6 hours) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) as first-line medications, despite the lack of strong evidence for their benefit in ICH patients, they are still considered due to their role in reducing intracranial pressure in other contexts.
• Sedation with propofol (5-80 mcg/kg/min) or midazolam (0.02-0.2 mg/kg/hr) to reduce metabolic demand.

Advanced Management

For patients not responding to initial measures, temporary relief can be achieved through:

• Hyperventilation to a PaCO2 of 30-35 mmHg, though this should not be maintained long-term due to risks of cerebral vasoconstriction.
• Refractory cases may require more aggressive interventions such as barbiturate coma with pentobarbital, therapeutic hypothermia (32-34°C), or surgical decompression through craniectomy.
• CSF drainage via ventriculostomy is effective for obstructive hydrocephalus.

These treatments aim to reduce cerebral blood volume, decrease brain water content, lower metabolic demand, or create space for the swollen brain to expand, with the ultimate goal of preventing secondary brain injury from sustained high pressure. It's essential to note that the management of intracranial hypertension should be tailored to the individual patient's needs and monitored closely for any signs of improvement or deterioration, as evidenced by studies such as those referenced in 1, 1, 1, and 1. However, the most recent guideline from 1 should guide clinical decision-making due to its recency and focus on spontaneous intracerebral hemorrhage.

From the FDA Drug Label

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

Reduction of Intracranial Pressure and Brain Mass: Adults: 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 treatment for intracranial hypertension is mannitol (IV). The recommended dosage is:

• For adults: 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes
• For 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 2

From the Research

Treatment Options for Intracranial Hypertension

The treatment for intracranial hypertension depends on the underlying cause and may involve a range of modalities, including:

• Surgical treatment for conditions such as hematoma, contusion, tumor, hygroma, hydrocephalus, or pneumatocephalus 3
• Correction of the patient's position, temperature, ventilation, or hemodynamics to control ICP 3
• Drainage of CSF via external drainage to reduce ICP 3
• Induced hypocapnea (hyperventilation) to reduce ICP, with a target paCO2 < 35 mmHg 3, 4
• Hyperosmolar therapy using mannitol or hypertonic saline to reduce ICP 3, 5, 6
• Induced arterial hypertension to maintain cerebral perfusion pressure 3

Medical Management

Medical management of intracranial hypertension may include:

• Administration of acetazolamide to decrease elevated CSF pressure, particularly in patients with cerebrospinal fluid leaks 7
• Use of barbiturates or other sedatives to reduce ICP, although this should be considered only in patients with refractory intracranial hypertension and no preexisting cardiovascular contraindications 4
• Consideration of alternative agents, such as etomidate, which may be effective in reducing ICP 4

Monitoring and Assessment

Monitoring and assessment of ICP is crucial in the management of intracranial hypertension, and may involve:

• Invasive measurement of ICP using direct ventricular manometry or measurement in the parenchyma with electronic or fiberoptic devices 3
• Displaying the time course of pressure (high-resolution ICP tonoscopy) to assess the validity of the signal and identify specific pathological findings 3
• Evaluation of the patient's clinical status, including age, CT diagnosis, responsiveness to hyperventilation, pressure-volume index, and ICP waveform, to guide treatment decisions 4