What are the management strategies for raised Intracranial Pressure (ICP)?

Management of Raised Intracranial Pressure

Immediate Initial Measures

Begin with head of bed elevation to 20-30 degrees with neck in neutral midline position to optimize jugular venous drainage and lower ICP. 1, 2 Avoid any neck rotation or flexion, as this directly obstructs internal jugular vein drainage and raises ICP. 1 Remove tight cervical collars or neck dressings that may compress the jugular veins. 1

Critical First Steps

• Ensure adequate oxygenation and avoid hypoxemia, hypercarbia, and hyperthermia, as these worsen ICP. 2, 1
• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg by managing blood pressure appropriately. 2, 1, 3
• Obtain emergent non-contrast CT head to identify hemorrhage, mass lesions, hydrocephalus, midline shift, and signs of herniation. 1
• Look specifically for ventricular effacement, midline shift, cerebral edema, and loss of basal cisterns as indicators of elevated ICP. 1

ICP Monitoring

ICP and CPP monitoring are recommended as part of protocol-driven care in patients at risk of elevated intracranial pressure based on clinical and/or imaging features. 2

• Consider ICP monitoring with intraventricular catheter or intraparenchymal probe for patients with GCS ≤8 or clinical evidence of herniation. 1
• Ventricular catheters are preferred as they allow both monitoring and therapeutic CSF drainage, particularly in patients with hydrocephalus. 2, 1
• Intraparenchymal monitors or ventricular catheters are the most reliable and accurate devices for measuring ICP. 2
• The threshold defining intracranial hypertension is generally considered to be >20-25 mmHg, though this remains somewhat uncertain. 2, 4

Stepwise Medical Management Protocol

Tier 1: First-Line Interventions

• Sedation and analgesia to achieve a quiet, motionless state and reduce metabolic demands. 2, 5
• Osmotic therapy with mannitol 0.25-2 g/kg IV administered over 30-60 minutes, with maximum dose of 2 g/kg. 2, 1, 6 In small or debilitated patients, 500 mg/kg may be sufficient. 6
• Hypertonic saline (3%) provides rapid ICP reduction and may be superior to mannitol in some cases. 1, 3 Use bolus dose of 2 mL/kg administered over 15-20 minutes. 3
• Maintain serum sodium 145-155 mmol/L when using hypertonic saline, not exceeding 155-160 mmol/L to prevent osmotic demyelination. 3

Tier 2: Second-Line Interventions

• CSF drainage via ventricular catheter if hydrocephalus is present. 2, 1
• Moderate hyperventilation targeting PaCO₂ 30-35 mmHg for short-term use only in impending herniation. 2, 3, 5
• Neuromuscular blockade in intubated patients with refractory ICP. 2

Tier 3: Refractory ICP Management

• High-dose pentobarbital therapy for ICP refractory to conventional measures. 5, 7
• Therapeutic cooling to 32-34°C can lower refractory intracranial hypertension but carries high complication rates including pulmonary, infectious, coagulation, and electrolyte problems. 2, 7

Surgical Interventions

Neurosurgical consultation is mandatory for potentially operable lesions such as hematoma evacuation, tumor resection, or abscess drainage. 1

• External ventricular drain placement for hydrocephalus provides both diagnostic and therapeutic benefit. 1
• Decompressive craniectomy may be life-saving for malignant cerebral edema refractory to medical management. 1, 4

Temperature and Seizure Management

• Treat fever aggressively to normal levels with antipyretics, as fever duration is related to outcome and causes intracranial hypertension. 2
• Treat clinical seizures with appropriate antiepileptic therapy (lorazepam 0.1 mg/kg IV/IO as first-line). 2, 8
• Avoid prophylactic anticonvulsants as they may increase mortality. 8

Critical Pitfalls to Avoid

• Never perform lumbar puncture before neuroimaging in patients with suspected elevated ICP, as this can precipitate herniation. 1
• Do not use corticosteroids for ICP management in intracerebral hemorrhage or ischemic stroke, as they are ineffective and potentially harmful. 1
• Avoid prophylactic hyperventilation, as excessive hypocapnia causes cerebral vasoconstriction and may worsen ischemia. 1, 5
• Do not use hypotonic fluids or excessive glucose administration, which worsen cerebral edema. 1
• Avoid rapid correction of PaCO₂ in patients with compensatory hyperventilation, as this can cause sudden ICP increases. 8
• Never allow activities that increase intrathoracic pressure (coughing, Valsalva maneuvers) as these raise ICP. 1

Monitoring Parameters

• Monitor serum sodium, osmolality, and renal function at baseline and within 6 hours of hypertonic saline administration. 3
• Maintain CPP between 60-90 mmHg to provide sufficient cerebral perfusion, as cerebral autoregulation may fail at CPP <60 or >100 mmHg. 7
• Evidence of reduced CSF pressure should be observed within 15 minutes after starting mannitol infusion. 6
• Careful evaluation of circulatory and renal reserve is required prior to and during mannitol administration at higher doses. 6