How do you manage a patient with elevated intracranial pressure?

Management of Elevated Intracranial Pressure

The management of elevated intracranial pressure (ICP) requires a tiered approach starting with basic measures, progressing to medical therapies, and culminating in surgical interventions when necessary to prevent secondary brain injury and reduce mortality.

Definition and Monitoring

Elevated intracranial pressure (intracranial hypertension) is defined as a sustained ICP above 20 mmHg 1. Proper monitoring is essential for diagnosis and management:

• Gold standard monitoring: Intraventricular catheter (allows both monitoring and therapeutic CSF drainage) 1
• Alternative options: Intraparenchymal monitors, transcranial Doppler ultrasonography 1
• Indications for monitoring:
  • Glasgow Coma Scale score ≤8 with abnormal CT scan
  • Severe traumatic brain injury
  • Intracerebral hemorrhage with neurological deterioration
  • Symptomatic hydrocephalus 1

Tiered Management Approach

Tier 1: Basic Measures

1. Patient positioning:

   • Elevate head of bed to 30° 2, 1
   • Maintain neutral neck alignment to avoid jugular compression 1

2. Airway and ventilation management:

   • Secure airway with endotracheal intubation for patients with GCS ≤8 or deteriorating mental status 2
   • Maintain normocapnia (PaCO₂ 35-40 mmHg) 1
   • Avoid prolonged hyperventilation (PaCO₂ <25 mmHg) as it can cause cerebral ischemia 2

3. Sedation and analgesia:

   • Use propofol or midazolam for sedation 1
   • Avoid sedation in early stages of encephalopathy if possible 2

4. Seizure management:

   • Treat clinical seizures with antiseizure medications 1
   • Consider continuous EEG monitoring for 24-48 hours in patients with altered mental status 1

5. Basic nursing measures:

   • Avoid patient straining during coughing, suctioning, or bowel movements
   • Reduce excessive environmental stimuli
   • Cluster nursing activities 2

Tier 2: Medical Therapies

1. Osmotic therapy:

   • Mannitol: 0.25-2 g/kg IV over 15-20 minutes 3

     • Monitor electrolytes and renal function
     • Effective for short-term ICP reduction but may require repeated doses 2

   • Hypertonic saline: Alternative to mannitol (3% solution) 2

     • May be more effective in reducing perihematomal edema 2

2. CSF drainage:

   • External ventricular drainage for patients with hydrocephalus 2, 1
   • Particularly effective when hydrocephalus is contributing to elevated ICP 1

3. Temperature management:

   • Treat fever promptly as it worsens outcomes 2
   • Consider targeted temperature management for refractory cases 2

4. Blood pressure management:

   • Target systolic BP <140 mmHg in hemorrhagic conditions 1
   • Avoid hypotension to maintain adequate cerebral perfusion pressure (CPP) 2

Tier 3: Surgical Interventions

1. Decompressive craniectomy:

   • Consider for refractory intracranial hypertension 2, 1
   • Minimum diameter of 12 cm for fronto-parieto-temporo-occipital craniectomy 1

2. Hematoma evacuation:

   • For large hematomas with mass effect causing neurological deterioration 1
   • Particularly important for cerebellar hemorrhage with brainstem compression 1

3. Specific neurosurgical indications:

   • Removal of symptomatic extradural hematoma
   • Removal of significant acute subdural hematoma (>5 mm thickness with >5 mm midline shift)
   • Drainage of acute hydrocephalus
   • Closure of open displaced skull fracture 2

Treatment Goals

• Maintain ICP <20 mmHg 1
• Maintain cerebral perfusion pressure (CPP) between 60-70 mmHg 1
• Prevent secondary brain injury from cerebral ischemia

Monitoring Response to Treatment

• Frequent neurological assessments to detect early signs of herniation 2
• Monitor ICP waveforms for trends rather than isolated readings 4
• Assess pupillary responses (unilateral sluggish or absent pupillary responses are reliable signs of increased ICP) 2

Common Pitfalls and Complications

• Prolonged hyperventilation can worsen cerebral ischemia 2, 1
• Volume overload can exacerbate cerebral edema 1
• Delayed recognition and treatment of hydrocephalus 1
• Renal insufficiency from osmotic therapy 1
• Electrolyte disturbances from diuretic therapy 1

By following this structured approach to managing elevated ICP, clinicians can effectively reduce the risk of secondary brain injury and improve patient outcomes in various neurological emergencies.