What are the clinical signs and evidence of increased intracranial pressure in a patient with a history of fall from height, presenting with vomiting, and a small hairline fracture on the posterior parietal region?

Clinical Signs and Evidence of Increased Intracranial Pressure

In a patient with fall from height, vomiting, and a hairline parietal fracture, you must immediately assess for declining consciousness, pupillary abnormalities, focal neurological deficits, and abnormal posturing—these are the key clinical signs of elevated intracranial pressure (ICP) that typically develop in later stages and constitute a medical emergency requiring urgent intervention. 1

Early Clinical Manifestations

The early phase of increased ICP presents with:

• Severe headache that characteristically worsens with Valsalva maneuvers (coughing, straining, bending forward) 1
• Vomiting, particularly projectile vomiting without preceding nausea, which is highly suggestive of elevated ICP 1
• Visual disturbances including blurred vision, diplopia, and visual field defects 1
• Altered mental status ranging from mild confusion to progressive decline in consciousness 1

In your specific case, the presence of vomiting after a fall with skull fracture is particularly concerning and warrants immediate neuroimaging and close monitoring. 2

Late-Stage Critical Signs

As ICP continues to rise, life-threatening signs emerge:

• Declining level of consciousness progressing from confusion to stupor and eventually coma 1, 3
• Pupillary abnormalities including asymmetry, sluggish or absent light response, and fixed dilated pupils 1, 3
• Focal neurological deficits such as hemiparesis or quadriparesis 3
• Abnormal posturing (decorticate or decerebrate posturing) indicating severe brain dysfunction 1, 3
• Respiratory abnormalities and eventual cardiopulmonary arrest if untreated 3

Ophthalmologic Findings

• Papilledema (optic disc swelling) visible on fundoscopic examination is a notable sign, though it may be absent in acute onset despite significantly elevated ICP 1
• Sixth nerve palsy (abducens nerve) causing incomitant esotropia, typically greater at distance, can indicate elevated ICP 1

Critical caveat: Papilledema takes time to develop and may not be present in acute ICP elevation, so its absence does not exclude dangerously elevated pressure. 1

Diagnostic Confirmation

Imaging Findings

Neuroimaging is crucial and should be performed urgently in your patient. CT findings suggesting elevated ICP include: 2

• Disappearance or compression of cerebral ventricles
• Brain midline shift >5 mm
• Compression of basal cisterns
• Intracerebral hematoma volume >25 mL 1

Direct Pressure Measurement

• Lumbar puncture opening pressure >200 mm H₂O (or >20 mmHg) indicates elevated ICP 1
• Invasive ICP monitoring via ventricular catheter or intraparenchymal probe is the gold standard for continuous measurement 3, 4

Important warning: Lumbar puncture is contraindicated if there is concern for mass effect or impending herniation, as it can precipitate brain herniation. Always obtain neuroimaging first in trauma patients. 3

Risk Stratification in Your Patient

Given the clinical context of fall from height with skull fracture and vomiting, specific risk factors for elevated ICP include:

• History of trauma with skull fracture increases risk of intracranial hemorrhage 2
• Vomiting is more common with intracranial hemorrhage than ischemic stroke 2
• Impaired consciousness if present, as Glasgow Coma Scale score is a powerful predictor of outcomes 1

Severity Thresholds and Prognosis

Understanding ICP severity helps guide urgency:

• ICP 20-40 mmHg: Associated with 3.95 times higher risk of mortality and poor neurological outcome, with consciousness typically impaired at these levels 1
• ICP >40 mmHg: Increases mortality risk 6.9 times and is almost universally associated with severe consciousness impairment or coma 1

Immediate Management Priorities

While awaiting definitive diagnosis, initial interventions should include:

• Head elevation to 20-30 degrees with neck in neutral midline position to promote venous drainage 5
• Ensure adequate oxygenation and avoid hypoxemia and hypercarbia which exacerbate cerebral edema 5
• Avoid hypo-osmolar fluids that may worsen cerebral edema 5
• Mannitol 0.5-1 g/kg IV over 5-10 minutes if clinical signs of herniation develop, with maximum effect within 10-15 minutes 5, 6

Critical pitfall: Do not delay neuroimaging to administer mannitol unless there are signs of imminent herniation. The priority is to identify surgically treatable lesions (epidural hematoma, subdural hematoma, depressed skull fracture) that require immediate neurosurgical intervention. 2, 7