What are the signs and symptoms of increased intracranial pressure (ICP)?

Signs and Symptoms of Increased Intracranial Pressure (ICP)

The most common signs and symptoms of increased intracranial pressure include headaches that worsen over time, nausea, vomiting, and blurred vision, which may be caused by tumor growth, brain swelling, or blocked cerebrospinal fluid flow. 1

Primary Clinical Manifestations

• Headache: Often severe and may worsen with Valsalva maneuvers (coughing, straining) 2
• Nausea and vomiting: Particularly projectile vomiting without preceding nausea 2
• Visual disturbances: Including blurred vision, diplopia (double vision), and visual field defects 2
• Papilledema: Swelling of the optic disc visible on fundoscopic examination 1, 2
• Altered mental status: Ranging from mild confusion to progressive decline in consciousness 2, 3

Advanced Signs (Late Presentation)

• Declining consciousness: Progressing from confusion to stupor and eventually coma 2, 3
• Focal neurological deficits: Including hemiparesis, monoparesis, and cranial nerve abnormalities 1
• Abnormal pupillary responses: Including dilated, sluggish, or nonreactive pupils 2, 3
• Abnormal posturing: Decorticate or decerebrate posturing in severe cases 2, 3
• Respiratory abnormalities: Changes in breathing patterns as ICP continues to rise 3
• Cushing's triad: Hypertension, bradycardia, and irregular respirations (late sign) 3

Age-Specific Manifestations

In Infants

• Bulging fontanelle: Tense or bulging anterior fontanelle 2, 4
• Increased head circumference: Progressive enlargement of head size 2, 4
• Separation of cranial sutures: Visible or palpable widening of suture lines 4
• Loss of developmental milestones: Regression in previously attained skills 1

In Children

• Poor school performance: Academic difficulties that may be new onset 1
• Fatigue: Excessive tiredness disproportionate to activity 1
• Personality changes: Behavioral alterations from baseline 1
• Seizures: May be a presenting symptom in pediatric patients 4

In Adolescents and Adults

• Sixth nerve palsy: Causing incomitant esotropia (convergent strabismus), typically greater at distance 2
• Memory impairment: Difficulty with recall and new learning 1
• Dysphasia/aphasia: Language difficulties depending on affected brain regions 1

Diagnostic Indicators

• Lumbar puncture: Opening pressure >200 mm H₂O indicates elevated ICP 2
• Neuroimaging findings: May show disappearance of cerebral ventricles, brain midline shift, compression of basal cisterns 2
• Transcranial Doppler: Can assess mass effect and track ICP changes 2

Clinical Patterns Based on Etiology

• Tumor-related ICP: Symptoms often develop gradually and worsen over time 1
• Pseudotumor cerebri/Idiopathic intracranial hypertension: More common in overweight females, with prominent headache and visual symptoms 1, 5
• Post-hemorrhagic ICP: May present suddenly with rapid neurological deterioration 4, 3
• Infection-related ICP: Often accompanied by fever and meningeal signs 4

Important Clinical Considerations

• Papilledema may be absent despite significantly elevated ICP, especially in acute onset cases 2
• Symptoms may occur gradually and worsen over time, or appear suddenly (e.g., with seizure) 1
• The clinical presentation depends largely on tumor location and patient age at diagnosis 1
• Increased ICP constitutes a medical emergency requiring immediate intervention when accompanied by declining consciousness or focal neurological deficits 2, 3

Common Pitfalls

• Relying solely on clinical signs may be unreliable, particularly in neonates 4
• Different pressure gradients may exist in and around mass lesions versus distant areas 4
• Indiscriminate use of sedatives may mask neurological deterioration 4
• Papilledema may take time to develop and may not be present in acute elevations of ICP 2