How is increased intracranial pressure (ICP) managed?

Management of Increased Intracranial Pressure (ICP)

A graded, stepwise approach should be implemented for managing increased intracranial pressure, starting with simple measures like head elevation and progressing to more aggressive interventions as clinically indicated, with the goal of maintaining cerebral perfusion pressure between 50-70 mmHg. 1

Initial Assessment and General Measures

• Head-of-Bed Elevation: Position head at 30° to improve jugular venous outflow and lower ICP 2

  • Keep head midline and avoid head turning to either side
  • Monitor blood pressure to ensure this doesn't compromise cerebral perfusion pressure (CPP)

• Analgesia and Sedation: Provide adequate pain control and sedation to minimize pain and ICP increases 2

  • Options include:
    • Propofol for sedation (may reduce cerebral blood flow)
    • Midazolam or etomidate for sedation
    • Morphine or alfentanil for analgesia and antitussive effect
  • Titrate to minimize pain while allowing neurological assessment

Monitoring

• Invasive ICP monitoring is indicated for patients with severe ICP elevation or clinical deterioration 2, 1
• Target cerebral perfusion pressure (CPP) between 50-70 mmHg 1
• CPP = Mean Arterial Pressure (MAP) - ICP

Pharmacological Management

Osmotic Diuretics

• Mannitol: First-line osmotic agent for rapid ICP reduction 3

  • Dosage: 0.25-2 g/kg body weight as a 15-25% solution over 30-60 minutes
  • For small or debilitated patients, 500 mg/kg may be sufficient
  • Evidence of reduced ICP should be observed within 15 minutes after starting infusion
  • Caution: Assess circulatory and renal reserve before administration
  • Mechanism: Increases plasma osmolarity, drawing fluid from intracellular to extracellular space

• Hypertonic Saline: Alternative to mannitol 1

  • Particularly useful when there are concerns about hypovolemia

Blood Pressure Management

• Target systolic BP of 140 mmHg within 6 hours of symptom onset in hemorrhagic stroke 1
• Maintain systolic BP <220 mmHg and diastolic BP <105 mmHg while avoiding sudden drops that may compromise cerebral perfusion 1

Cerebrospinal Fluid (CSF) Drainage

• External ventricular drainage (EVD) is effective for lowering ICP, particularly with hydrocephalus 2, 1
• Risks include infection (bacterial colonization 0-19%) and hemorrhage
• Indicated for patients with intraventricular hemorrhage with hydrocephalus or significant hydrocephalus requiring CSF diversion 1

Advanced Measures for Refractory ICP

Neuromuscular Blockade

• Consider if patient is not responsive to analgesia and sedation alone 2
• Helps reduce intrathoracic pressure and improve cerebral venous outflow
• Caution: Makes neurological assessment difficult

Hyperventilation

• Moderate hyperventilation (PaCO2 26-30 mmHg) can be used for short periods 4
• Caution: Prolonged or aggressive hyperventilation may cause cerebral ischemia 2
• Non-selective hyperventilation may enhance secondary brain injury 2

Barbiturates

• High-dose barbiturate therapy for refractory ICP 4
• Associated with cardiovascular and respiratory depression and prolonged coma 2

Hypothermia

• Systemic cooling to 34°C can be effective for refractory intracranial hypertension 2
• Associated with complications including pulmonary, infectious, coagulation, and electrolyte problems
• Significant ICP rebound may occur during rewarming 2

Surgical Management

• Surgical evacuation for cerebellar hemorrhage >3 cm, brainstem compression, or hydrocephalus 1
• Consider decompressive craniectomy for refractory ICP 5

Additional Considerations

• Avoid:

  • Corticosteroids for ICP treatment in hemorrhagic stroke 1
  • Hypotonic fluids 1
  • Hypotension 1

• Maintain:

  • Normothermia (temperature <37.5°C) 1
  • Serum glucose between 140-180 mg/dL 1
  • Appropriate seizure management (treat clinical seizures with phenytoin) 2, 1

Special Considerations

• Many patients with smaller intracerebral hemorrhages may not have increased ICP and require no specific measures 2
• The more aggressive the ICP management measures, the more critical the need to monitor ICP and CPP 2
• Early mobilization and rehabilitation are recommended for clinically stable patients 1
• DVT prophylaxis with intermittent pneumatic compression devices is recommended 1

Remember that management should follow a balanced approach, starting with simple measures and progressing to more aggressive interventions only as needed based on clinical response and ICP monitoring.