What is the treatment for raised intracranial pressure?

Treatment of Raised Intracranial Pressure

The management of raised intracranial pressure requires a tiered approach starting with basic measures like head elevation and proper ventilation, followed by osmotic therapy with mannitol (0.5-1 g/kg) or hypertonic saline, and escalating to surgical interventions for refractory cases.

Clinical Assessment and Monitoring

• Monitor for signs of increased intracranial pressure (ICP):

  • Early signs: Headache, nausea, vomiting, papilledema
  • Late signs: Declining consciousness, focal neurological deficits, unequal/dilated pupils, abnormal posturing 1
  • Cushing's triad (hypertension, bradycardia, irregular respiration) is a late finding

• Goals of management:

  • Maintain ICP below 20-25 mmHg
  • Maintain cerebral perfusion pressure (CPP) above 60-70 mmHg 1, 2

First-Tier Interventions

1. Position and Airway Management:

   • Elevate head of bed by 20-30° to improve venous drainage 3, 1
   • Ensure neutral neck alignment to prevent jugular venous compression
   • Maintain adequate oxygenation (PaO₂ ≥ 60-100 mmHg) 1

2. Ventilation Management:

   • Maintain normocapnia (PaCO₂ 35-40 mmHg) 1
   • Short-term hyperventilation (PaCO₂ 25-30 mmHg) only for acute, life-threatening ICP elevations 1, 4
   • Caution: Prolonged hyperventilation can cause cerebral vasoconstriction and ischemia

3. Sedation and Analgesia:

   • Provide adequate sedation to minimize pain and ICP increases 1
   • Avoid fluctuations in arterial blood pressure

4. Fluid Management:

   • Mild restriction of fluids 3
   • Avoid hypo-osmolar fluids (e.g., 5% dextrose) which may worsen cerebral edema 3
   • Correct electrolyte abnormalities 3

5. Temperature Control:

   • Maintain normothermia and treat fever aggressively 1

Second-Tier Interventions (Osmotic Therapy)

1. Mannitol:

   • First-line osmotic agent for acute ICP elevation 1, 5
   • Dosage: 0.5-1 g/kg IV bolus over 30-60 minutes 1, 5
   • May repeat once or twice if serum osmolality <320 mOsm/L 1
   • Mechanism: Creates osmotic gradient to draw water from brain tissue into vascular space 5
   • Monitor for renal function, as mannitol is contraindicated in anuria due to severe renal disease 5

2. Hypertonic Saline:

   • Alternative osmotic agent, especially for refractory cases 3, 1
   • Concentrations range from 3% to 23.5% 3
   • Effective in reducing ICP in traumatic brain injury and subarachnoid hemorrhage 3
   • Monitor electrolytes closely, particularly sodium levels

Third-Tier Interventions

1. CSF Drainage:

   • Ventricular drainage for hydrocephalus 1
   • Options include:
     • Intermittent drainage via intraventricular catheter
     • Continuous external ventricular drainage
     • Lumbar drainage (if no risk of herniation) 1

2. Barbiturate Coma/Metabolic Suppression:

   • For refractory intracranial hypertension 6
   • Reduces cerebral metabolic demand and blood flow

3. Surgical Interventions:

   • Evacuation of mass lesions (hematomas, tumors) causing significant mass effect 1
   • Decompressive craniectomy for refractory intracranial hypertension 1, 6
   • Particularly beneficial in large cerebellar or hemispheric infarcts 1

Special Considerations

• Steroids: Beneficial for cerebral edema due to tumors but not recommended for traumatic brain injury or spontaneous intracerebral hemorrhage 1

• Seizure Management: Control seizures with appropriate antiepileptic therapy to prevent further increases in ICP 1

• Blood Pressure Management:

  • Maintain adequate systemic blood pressure to ensure sufficient CPP
  • Avoid aggressive treatment of hypertension which may decrease CPP 1

• Monitoring Complications:

  • Renal failure with osmotic therapy
  • Electrolyte imbalances (particularly hypernatremia or hyponatremia)
  • Rebound intracranial hypertension
  • Pulmonary edema 5

The management approach should be adjusted based on the underlying cause of increased ICP, with continuous monitoring of neurological status and treatment response to guide escalation of therapy.