What are the treatments for elevated Intracranial Pressure (ICP)?

From the Guidelines

To lower high intracranial pressure (ICP), the most effective treatment approach is to use a combination of interventions, including elevating the head of the bed, administering osmotic diuretics like mannitol or hypertonic saline, and using sedation and neuromuscular blockade as needed, as recommended by the most recent guidelines from the American Heart Association/American Stroke Association in 2022 1.

Treatment Options

The treatment of elevated ICP involves a multifaceted approach, including:

• Elevating the head of the bed to 30-45 degrees to promote venous drainage from the brain
• Administering osmotic diuretics like mannitol (0.25-1 g/kg IV every 4-6 hours) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) to reduce brain water content, with hypertonic saline being more effective than mannitol in some cases 1
• Using hyperventilation temporarily to achieve a PaCO2 of 30-35 mmHg, causing cerebral vasoconstriction
• Sedation with propofol (5-80 mcg/kg/min) or midazolam (0.05-0.2 mg/kg/hr) to reduce cerebral metabolic demand
• Neuromuscular blockade with agents like vecuronium (0.1 mg/kg loading dose, then 0.05-0.1 mg/kg/hr) for severe cases to prevent activities that increase ICP
• Temperature control, targeting normothermia or mild hypothermia (36-37°C)
• CSF drainage via an external ventricular drain for immediate pressure relief
• Surgical decompression for space-occupying lesions or refractory ICP elevation ### Rationale These interventions work by reducing brain volume through decreasing cerebral blood volume, brain water content, or creating more space for the brain to expand, following the Monroe-Kellie doctrine which states that the sum of brain tissue, CSF, and blood volume must remain constant within the fixed cranial vault 2, 3.

Considerations

It is essential to note that the optimal treatment approach may vary depending on the underlying cause of the elevated ICP, and individual patient factors, such as the presence of other medical conditions or concomitant medications, should be taken into account when selecting a treatment strategy 4.

From the FDA Drug Label

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

12 CLINICAL PHARMACOLOGY 12. 1 Mechanism of Action ... By increasing the osmotic pressure of plasma and the extracellular space, intravenously administered mannitol will induce the movement of intracellular water to the extracellular and vascular spaces. This action underlies the role of mannitol in reducing intracranial pressure, intracranial edema, and intraocular pressure.

The treatment for elevated Intracranial Pressure (ICP) is mannitol (IV), which works by increasing the osmotic pressure of plasma and the extracellular space, inducing the movement of intracellular water to the extracellular and vascular spaces, thereby reducing intracranial pressure and intracranial edema [5] [6].

• Key mechanism: Osmotic diuretic effect
• Key benefit: Reduction of intracranial pressure and brain mass

From the Research

Treatments for Elevated Intracranial Pressure (ICP)

The following are treatments for elevated ICP:

• Head elevation 7, 8
• Hyperventilation 7, 9, 10, 8
• Mannitol infusion 7, 9, 10, 8
• High-dose pentobarbital therapy 7, 9
• Moderate hypothermia 7, 10, 8
• Placement of an ICP monitor 7
• Sedation 7, 9, 8, 11
• Control of blood pressure to keep cerebral perfusion pressure (CPP) >70 and <120 7
• Osmotic diuretics (e.g., urea, glycerol) 9
• Loop diuretics (e.g., furosemide, ethacrynic acid) 9
• Corticosteroids 9
• CSF drainage via external drainage 10, 8
• Induced hypocapnea (paCO2 < 35 mmHg) 10
• Hyperosmolar therapy (hypertonic saline) 10, 8
• Induced arterial hypertension (CPP concept) 10
• Hyperoncotic treatment aimed at reducing vasogenic edema and intracranial blood volume 10
• Barbiturate coma 9, 10, 11
• Emergent bilateral decompressive craniectomy 10
• Nursing care, including collaboration with an interprofessional team and direction toward patient and family comfort 11

Surgical Options

Surgical options for treating elevated ICP include:

• CSF drainage if hydrocephalus is present 8
• Decompression of a surgical lesion, such as an intracranial hematoma/large infarct or tumor, if the patient's condition is deemed salvageable 8

Medical Options

Medical options for treating elevated ICP include:

• IV mannitol 8
• Hypertonic saline 8
• Transient hyperventilation 8
• Barbiturates 8
• Sedation, endotracheal intubation, mechanical ventilation, and neuromuscular paralysis if ICP remains refractory 8