From the Guidelines
Patients with increased intracranial pressure (ICP) and a history of intracerebral hemorrhage (ICH) should be managed with a comprehensive approach that targets maintaining ICP below 20-22 mmHg and cerebral perfusion pressure above 60 mmHg, with first-line interventions including elevating the head of bed, ensuring adequate oxygenation and ventilation, and hyperosmolar therapy with mannitol or hypertonic saline, as recommended by the 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage 1.
Initial Assessment and Management
Initial assessment should include neurological examination, vital signs monitoring, and head CT imaging to evaluate the current status of the hemorrhage and degree of cerebral edema.
- Key interventions include:
- Elevating the head of bed to 30 degrees
- Maintaining neck alignment
- Ensuring adequate oxygenation and ventilation
- Hyperosmolar therapy with mannitol (0.25-1 g/kg IV every 4-6 hours) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) for acute ICP elevation
Blood Pressure Control
Blood pressure control is crucial in ICH patients, with a target systolic blood pressure below 140 mmHg using labetalol (10-20 mg IV bolus, then 0.5-2 mg/min) or nicardipine (5-15 mg/hr), as supported by the 2022 guideline 1.
Refractory ICP and Surgical Interventions
For refractory ICP, consider neuromuscular blockade with vecuronium (0.1 mg/kg loading dose, then 0.05-0.1 mg/kg/hr) and therapeutic hypothermia (32-34°C). Surgical interventions including external ventricular drainage or decompressive craniectomy may be required for severe cases, as suggested by the 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage 1.
From the FDA Drug Label
Active intracranial bleeding except during craniotomy ( 4) The FDA drug label does not answer the question.
From the Research
Patient Presentation of ICP with History of ICH
The patient presentation of increased intracranial pressure (ICP) with a history of intracerebral hemorrhage (ICH) is a complex condition that requires careful management.
- Elevated ICP may lead to brain damage or death by two principle mechanisms: global hypoxic-ischemic injury and mechanical distortion and compression of brain tissue 2.
- The treatment of ICP should proceed in an orderly step-wise fashion, including consideration of neuroimaging, intravenous sedation, manipulation of blood pressure, mannitol infusion, moderate hyperventilation, and high-dose pentobarbital therapy 2.
Treatment Options for ICP
Several treatment options are available for managing ICP in patients with a history of ICH, including:
- Mannitol: a widely used osmotic diuretic that can help reduce ICP 2, 3, 4, 5.
- Hypertonic saline: a hyperosmolar solution that can help reduce ICP, with some studies suggesting it may be more effective than mannitol 3, 6.
- Moderate hypothermia: a newer method for treating refractory ICP, which shows promise in reducing ICP 2.
Efficacy of Mannitol in Reducing ICP
The efficacy of mannitol in reducing ICP has been questioned, with some studies suggesting it may not be effective in reducing ICP in all patients 4.
- A systematic review and meta-analysis found that mannitol was effective in reducing ICP, but the evidence was not strong enough to support its routine use in all patients with supratentorial hypertensive intracerebral hemorrhage 4.
- An individual patient data meta-analysis found that mannitol was effective in reducing ICP, proportionally to the degree of intracranial hypertension, but the dose did not influence ICP reduction 5.
Comparison of Hypertonic Saline and Mannitol
Several studies have compared the efficacy of hypertonic saline and mannitol in reducing ICP, with some suggesting that hypertonic saline may be more effective 3, 6.
- A review article found that while hypertonic saline may be more effective than mannitol in reducing ICP, there is insufficient evidence to support a formal recommendation on the use of any specific hyperosmolar medication in patients with acute increased intracranial pressure 6.