What is the management of raised intracranial tension (ICT) in a patient?

Management of Raised Intracranial Pressure (ICT)

The management of raised intracranial pressure requires immediate intervention with a stepwise approach including head elevation, osmotherapy with mannitol, ventilatory support, and CSF drainage in refractory cases. 1, 2

Initial Assessment and Immediate Interventions

• Recognize signs of raised ICT: declining consciousness, focal neurological deficits including unequal/dilated/poorly responsive pupils, abnormal posturing, headache, papilledema (late finding), and hypertension with relative bradycardia (late finding) 3
• Establish and secure airway, provide adequate oxygenation, and ensure proper ventilation to prevent hypoxemia and hypercarbia which exacerbate cerebral edema 1
• Elevate head of bed to 20-30° to promote venous drainage and reduce intracranial pressure, ensuring head is midline to avoid impeding venous outflow 3
• Restrict free water and avoid hypo-osmolar fluids (such as 5% dextrose in water) that may worsen cerebral edema 3, 1
• Correct factors that exacerbate raised ICT: hypoxia, hypercarbia, and hyperthermia 3, 1

First-Line Medical Management

• Administer mannitol as first-line osmotic therapy at a dose of 0.25-2 g/kg body weight as a 15-25% solution over 30-60 minutes 4
  • Maximum effect occurs within 10-15 minutes with duration of 2-4 hours 1, 2
  • For small or debilitated patients, a lower dose of 500 mg/kg may be sufficient 4
• Monitor for mannitol side effects including fluid/electrolyte imbalances, renal failure, and rebound intracranial hypertension 3, 4
• Consider hypertonic saline as an alternative osmotic agent when mannitol is contraindicated or ineffective 1, 2
• Avoid antihypertensive agents, particularly those that induce cerebral vasodilation, as elevated blood pressure may be a compensatory response to maintain cerebral perfusion 3

Advanced Management for Refractory Cases

• CSF drainage via ventriculostomy is highly effective when hydrocephalus is present 3
  • Be aware of risks including infection (6-22% bacterial meningitis) and hemorrhage (2-4%) 3
• Provide adequate analgesia and sedation to minimize pain and prevent increases in ICP while still allowing neurological assessment 3
• Consider short-term hyperventilation (target PCO₂ ≈ 30 mmHg) only for impending herniation, as prolonged hyperventilation may worsen outcomes 2, 5
• For patients with refractory intracranial hypertension, consider barbiturate coma or decompressive surgery in selected cases 6

Monitoring and Targets

• Monitor ICP when indicated, particularly in patients with abnormal CT findings 3
  • An ICP of 20-40 mmHg is associated with 3.95 times higher risk of mortality 3, 2
  • When ICP exceeds 40 mmHg, mortality risk increases 6.9 times 3, 2
• Maintain cerebral perfusion pressure (CPP) between 60-70 mmHg 1, 2
  • Avoid CPP <60 mmHg (associated with worse outcomes) and >90 mmHg (may worsen vasogenic edema) 1, 7
• Perform serial neurological examinations to detect deterioration early 3, 8

Special Considerations

• CT scan findings suggestive of raised ICT include disappearance of cerebral ventricles, brain midline shift >5 mm, intracerebral hematoma volume >25 mL, and compression of basal cisterns 3
• ICP monitoring is not routinely indicated if the initial CT scan is normal with no evidence of clinical severity 3
• Steroids are not recommended for management of raised ICT in most acute settings, as their effect remains unclear and may adversely affect outcomes 3
• In patients with cryptococcal meningitis, lumbar drainage is the principal intervention for reducing elevated intracranial pressure 3

Pitfalls to Avoid

• Delaying treatment of raised ICT can lead to cerebral ischemia, brain herniation, and death 8, 7
• Excessive fluid restriction can lead to hypovolemia and decreased cerebral perfusion 3
• Rapid correction of long-standing hypertension may reduce cerebral perfusion pressure 3
• Overaggressive hyperventilation can cause cerebral vasoconstriction and ischemia 2, 6
• Failure to recognize that mannitol's effect is temporary, requiring repeated doses in some cases 3

The management of raised ICT requires prompt recognition and aggressive intervention to prevent secondary brain injury and improve outcomes 5, 9.