What is the management for a patient presenting with symptoms of raised intracranial pressure (ICP)?

Management of Raised Intracranial Pressure (ICP)

The management of a patient with raised intracranial pressure requires immediate intervention with a stepwise approach focused on preventing cerebral herniation and maintaining adequate cerebral perfusion pressure (CPP) to reduce mortality and improve neurological outcomes.

Initial Assessment and Stabilization

Signs and Symptoms of Raised ICP

• Early signs: Headache, nausea, vomiting, papilledema
• Progressive signs: Declining consciousness, focal neurological deficits
• Late signs: Unequal/dilated/poorly responsive pupils, abnormal posturing, hypertension with relative bradycardia (Cushing's triad)

Immediate Interventions

1. Airway management

   • Secure airway if GCS < 8 or deteriorating
   • Avoid hypoxemia (maintain PaO₂ ≥ 60-100 mmHg) 1

2. Position patient

   • Elevate head of bed 20-30° while maintaining neutral neck alignment 1
   • Avoid neck compression that may impede venous return

3. Respiratory management

   • Maintain normocapnia (PaCO₂ 35-40 mmHg) 1
   • Brief hyperventilation (target PaCO₂ 25-30 mmHg) only for acute herniation signs 2
   • Avoid routine hyperventilation as it may cause cerebral ischemia 1

Tiered Management Approach

First-Tier Interventions

1. Osmotic therapy

   • Mannitol 0.5-1 g/kg IV bolus over 15-20 minutes 2, 1
   • Can repeat once or twice if needed (monitor serum osmolality, keep < 320 mOsm/L) 2
   • Alternative: Hypertonic saline (3%) for perihematomal edema reduction 1

2. CSF drainage

   • If hydrocephalus present, external ventricular drainage is first-line 1
   • Perform lumbar puncture only if no clinical contraindications indicating brain shift 2

3. Sedation and analgesia

   • Propofol may be used cautiously in patients with raised ICP 3
   • When using propofol in neurosurgical patients:
     • Administer as slow bolus (~20 mg every 10 seconds) or infusion 3
     • Avoid rapid boluses that can cause significant hypotension 3
     • Combine with hyperventilation and hypocarbia when increased ICP is suspected 3

Second-Tier Interventions (for refractory ICP)

1. ICP monitoring

   • Consider in patients with GCS < 8 or deteriorating neurological status
   • Target ICP < 20-25 mmHg 2
   • Maintain CPP > 50-60 mmHg (ideally 70-90 mmHg) 2, 1

2. Metabolic management

   • Maintain normoglycemia 1
   • Treat fever aggressively 1
   • Avoid hypo-osmolar fluids 2

3. Advanced pharmacologic therapy

   • Barbiturate coma for refractory intracranial hypertension 1
   • Requires close hemodynamic monitoring and vasopressor support

Third-Tier Interventions

1. Decompressive craniectomy

   • Consider for refractory intracranial hypertension 1
   • May be performed with or without hematoma evacuation

2. Moderate hypothermia

   • Target temperature of 35°C may reduce perihematomal edema 1

Special Considerations

Contraindications to Immediate Lumbar Puncture

• Clinical signs of raised ICP with potential brain shift 2
• Coagulopathy (requires correction before LP) 2
• If LP is contraindicated, perform CT scan as soon as possible 2

Etiology-Specific Management

• Viral encephalitis: Antiviral therapy (acyclovir) should be started empirically 2
• Acute liver failure: Monitor for cerebral edema; consider prophylactic measures 2
• Stroke: Careful management of blood pressure; consider decompression for malignant MCA infarction 2

Monitoring and Follow-up

• Frequent neurological evaluations using Glasgow Coma Scale 1
• Multimodal monitoring including ICP, CPP, and when available, cerebral blood flow 1
• For patients with ICP monitors, reassess need for continued monitoring daily

Complications to Watch For

• Herniation syndromes (uncal, central, tonsillar)
• Secondary ischemia
• Hydroelectrolytic disturbances from osmotic therapy 1
• Renal insufficiency due to osmotic diuretics 1

Remember that an ICP of 20-40 mmHg is associated with a 3.95-fold increased risk of mortality, while an ICP >40 mmHg increases mortality risk 6.9-fold 1. Early, aggressive management is essential for improving outcomes.