What is the appropriate management for a patient presenting with symptoms of increased intracranial pressure?

Management of Increased Intracranial Pressure

For patients presenting with symptoms of increased intracranial pressure, the cornerstone of management is aggressive CSF drainage via therapeutic lumbar puncture to reduce opening pressure by 50% or to ≤20 cm H₂O, while avoiding acetazolamide and corticosteroids which are contraindicated. 1

Initial Assessment and Diagnostic Approach

Pre-Lumbar Puncture Evaluation

• Obtain brain imaging (CT or MRI) BEFORE lumbar puncture if the patient has focal neurological signs, impaired mentation, or papilledema to rule out mass lesions that contraindicate lumbar puncture and increase herniation risk 1, 2
• In patients without these contraindications, perform lumbar puncture immediately to measure opening pressure and obtain CSF for analysis 1, 2

Defining Elevated ICP

• Opening pressure ≥25 cm H₂O (approximately ≥18 mmHg) is defined as elevated and requires intervention when accompanied by symptoms 1, 3
• Normal opening pressure is <20-25 cm H₂O 3
• Extremely high pressures (>40 cm H₂O or >29 mmHg) indicate severe intracranial hypertension requiring aggressive management 3

Clinical Manifestations to Recognize

Common Symptoms and Signs

• Severe headache, altered mental status, and papilledema are cardinal features 1
• Cranial nerve abnormalities including hearing loss, loss of visual acuity, and diplopia 1, 3
• Pathological reflexes and abnormal posturing 1
• Nausea and vomiting 1
• Gait difficulties and radicular signs 1

Critical Warning Signs

• Unilateral sluggish or absent pupillary responses are the only reliable signs of acute raised ICP in children and should prompt immediate intervention 1
• Declining conscious level with focal neurology suggests impending herniation 1

Therapeutic Management Algorithm

Step 1: Immediate CSF Drainage (First-Line Therapy)

For opening pressure ≥25 cm H₂O with symptoms, perform therapeutic lumbar puncture removing sufficient CSF to reduce opening pressure by 50% if extremely high, or to achieve closing pressure ≤20 cm H₂O 1, 3

• Document both opening and closing pressures 3
• This is the principal intervention with strongest evidence 1

Step 2: Serial Lumbar Punctures for Persistent Elevation

• If pressure remains ≥25 cm H₂O with persistent symptoms, repeat lumbar puncture daily until CSF pressure and symptoms stabilize for >2 days 1, 2
• Failure to measure and manage elevated CSF pressure results in new neurologic abnormalities in 50% of patients versus 8% when guidelines are followed 2

Step 3: Temporary Drainage Devices

• For patients requiring repeated daily lumbar punctures beyond 2 days, consider temporary percutaneous lumbar drain or ventriculostomy 1, 2
• Lumbar drains can be safely maintained for up to 13 days with bacterial superinfection risk <5% 2
• Ventriculostomy is indicated for obstructive hydrocephalus or when lumbar puncture is contraindicated 2

Step 4: Permanent Shunting

• Permanent ventriculoperitoneal shunts should only be placed after appropriate therapy has been initiated and conservative measures have failed 1, 2
• VP shunts can be placed during active infection if clinically necessary 1, 2

Critical Medications to AVOID

Contraindicated Therapies

• Acetazolamide should be avoided—a randomized trial was stopped prematurely due to severe metabolic acidosis and complications 1, 2
• Corticosteroids should be avoided for ICP control (unless treating IRIS)—mortality and clinical deterioration were observed more commonly in corticosteroid recipients 1, 2
• Mannitol has no proven benefit in cryptococcal meningitis and is not routinely recommended 1

Context-Specific Mannitol Use

• In traumatic brain injury or other non-infectious causes, mannitol (0.5-1 g/kg) may be effective for short-term ICP reduction, but requires repeated doses due to brief duration of action 1, 4
• The FDA-approved dose for reduction of intracranial pressure is 0.25 to 2 g/kg as a 15-25% solution over 30-60 minutes 4

Etiology-Specific Considerations

Cryptococcal Meningitis

• Elevated ICP occurs in >50% of cases and is a major contributor to mortality—93% of deaths within the first 2 weeks had baseline ICP ≥25 cm H₂O 1, 2
• CSF typically shows minimal inflammation but uncontrolled fungal growth with high antigen titers 1
• The elevated pressure is thought to result from interference with CSF reabsorption in arachnoid villi caused by high levels of fungal polysaccharide antigen 1

Malaria with Cerebral Involvement

• Brain swelling is a major feature in fatal cases, though signs typically develop in later stages 1
• Rapid induction of anesthesia, intubation, and mechanical ventilation are indicated when features of raised ICP develop 1
• Maintain PaCO₂ within normal range to stabilize cerebral blood flow 1

Leptomeningeal Metastasis

• Symptoms related to CSF circulation disturbances can be rapidly alleviated by lowering ICP through CSF drainage 1
• Distinguish LM-related symptoms from parenchymal metastases or treatment side effects 1

Monitoring and Follow-Up

Ongoing Assessment

• For patients with normal baseline opening pressure, repeat lumbar puncture at 2 weeks after therapy initiation to exclude elevated pressure 1
• Follow-up lumbar punctures should be performed if new symptoms or clinical findings occur 1, 3
• Serial measurement of CSF opening pressure is more useful than serum biomarkers for monitoring response 3

General ICP Management Principles

• The overall goal is to maintain ICP <20 mmHg and cerebral perfusion pressure between 60-90 mmHg 5, 6
• In unmonitored patients with acute deterioration, head elevation, hyperventilation, and mannitol can rapidly lower ICP in traumatic/non-infectious causes 7

Common Pitfalls to Avoid

• Do not diagnose raised ICP in the peri-ictal state where pupillary signs and conscious level may be misleading 1
• Never perform lumbar puncture without imaging in patients with focal signs or altered mentation 1, 2
• Do not rely on papilledema or hypertension with bradycardia as early signs—these are late findings in acute raised ICP 1
• Avoid placing 25% mannitol in PVC bags as a white precipitate may form 4