What are the guidelines for catheter management of intracranial pressure (ICP)?

Guidelines for Catheter Management of Intracranial Pressure (ICP)

Ventricular drainage is the preferred treatment for hydrocephalus in patients with decreased level of consciousness, while ICP monitoring should be considered for patients with GCS ≤8, clinical evidence of transtentorial herniation, or significant intraventricular hemorrhage. 1

Indications for ICP Monitoring

• ICP monitoring should be considered for patients with:

  • Glasgow Coma Scale (GCS) score of 8 or less 1
  • Clinical evidence of transtentorial herniation 1
  • Significant intraventricular hemorrhage (IVH) or hydrocephalus 1
  • Supratentorial intracerebral hemorrhage (ICH), particularly in younger patients 1

• ICP monitoring should be part of protocol-driven care in patients at risk of elevated intracranial pressure based on clinical and/or imaging features 1

Types of ICP Monitoring Devices

• Two primary types of monitoring devices are used:

  • Ventricular catheters (VC): Allow for both ICP monitoring and cerebrospinal fluid (CSF) drainage 1
  • Parenchymal catheters (PC): Allow for ICP monitoring only, without CSF drainage 1

• In patients with hydrocephalus, ventricular catheters are preferred over parenchymal monitors when safe and practical 1

Procedural Considerations

• Before insertion of any monitoring device:

  • Evaluate the patient's coagulation status 1
  • Consider platelet transfusion for patients on prior antiplatelet therapy 1
  • Reverse coagulopathy in patients on warfarin 1

• Standard insertion and maintenance protocols should be followed to ensure safety and reliability 1

• Risks associated with ICP monitors include:

  • Infection: 2.9-4% (higher with ventricular catheters) 1, 2
  • Intracranial hemorrhage: 2.1-3% (15.3% in patients with coagulopathies) 1, 2
  • Malposition: More common with ventricular catheters (20.1%) 2

Management of Elevated ICP

• Target a cerebral perfusion pressure (CPP) of 50-70 mmHg, depending on the status of cerebral autoregulation 1

• Treatment should follow a stepwise approach:

  1. First-tier interventions:

     • Head of bed elevation to 30° with head midline 1, 3
     • Analgesia and sedation 1
     • Maintaining adequate cerebral perfusion pressure 3

  2. Surgical options:

     • CSF drainage via ventricular catheter for hydrocephalus 1
     • Evacuation of mass lesions if indicated 4

  3. Medical management for refractory ICP:

     • Osmotic therapy (mannitol or hypertonic saline) 4, 5
     • Avoid corticosteroids as they should not be administered for treatment of elevated ICP in ICH 1

  4. Advanced options for refractory cases:

     • Hypothermia 1, 5
     • Metabolic suppression (barbiturates) 1, 5
     • Decompressive craniectomy 5

Monitoring Considerations

• ICP should be continuously assessed, including waveform quality, using a structured protocol 1

• Instantaneous ICP values should be interpreted in context of monitoring trends, CPP, and clinical evaluation 1

• While refractory ICP elevation strongly predicts mortality, ICP alone is not a useful prognostic marker of functional outcome 1

• Normal ICP is below 15 mmHg; intracranial hypertension is defined as sustained ICP greater than 20-25 mmHg 4, 5

Special Considerations

• Hydrocephalus is associated with poor outcomes in ICH patients and is present in approximately 55% of patients with IVH 1

• The decision to use ventricular versus parenchymal monitoring should be based on whether there is a need to drain CSF to treat hydrocephalus or elevated ICP 1

• Differential pressure gradients may exist in ICH, with ICP elevated near the hematoma but not distant from it 1

• Patients with small hematomas and limited IVH usually will not require treatment to lower ICP 1