From the Guidelines
Elevated intracranial pressure (ICP) can lead to several serious complications, including brain herniation, hydrocephalus, cerebral ischemia, seizures, vision problems, and autonomic dysfunction, emphasizing the need for prompt management to prevent morbidity and mortality. The most severe complication is brain herniation, where brain tissue is forced through small openings in the skull, potentially causing permanent brain damage or death 1. Patients may develop hydrocephalus, an abnormal buildup of cerebrospinal fluid that further increases pressure. Cerebral ischemia can occur as elevated ICP reduces cerebral perfusion pressure, leading to inadequate blood flow and oxygen delivery to brain tissue. Seizures are common due to irritation of brain tissue. Vision problems, including papilledema (swelling of the optic disc) and potential blindness, may develop from pressure on the optic nerve. Patients often experience severe headaches, vomiting, altered consciousness, and cognitive impairments. Autonomic dysfunction can manifest as Cushing's triad (hypertension, bradycardia, and irregular breathing).
Management of Elevated ICP
Management typically includes:
- Elevation of the head to 30 degrees
- Osmotic diuretics like mannitol (0.25-1 g/kg IV) or hypertonic saline (3% solution)
- Hyperventilation to PaCO2 of 30-35 mmHg for acute management
- Sedation with propofol or midazolam
- Possibly surgical interventions such as external ventricular drainage or decompressive craniectomy for refractory cases Continuous ICP monitoring is essential for guiding treatment in severe cases, as it allows for the detection of increased ICP and the implementation of appropriate interventions to prevent further complications 1.
Key Considerations
- The decision to monitor and treat elevated ICP should be based on the individual patient's clinical presentation and the presence of symptoms such as headache, vomiting, and altered consciousness 1.
- The use of ICP monitoring devices, such as ventricular catheters or parenchymal catheters, should be considered in patients with severe ICH or those who are at high risk of developing elevated ICP 1.
- The management of elevated ICP should be tailored to the underlying cause, whether it be hydrocephalus, mass effect from the hematoma, or other factors 1.
Recent Guidelines
Recent guidelines emphasize the importance of managing elevated ICP in patients with ICH, and recommend a balanced approach that takes into account the individual patient's clinical presentation and the presence of symptoms 1. The guidelines also highlight the need for continuous ICP monitoring in severe cases, and the use of interventions such as osmotic diuretics, hyperventilation, and sedation to manage elevated ICP. Surgical interventions, such as external ventricular drainage or decompressive craniectomy, may also be considered in refractory cases.
From the FDA Drug Label
- 3 Central Nervous System (CNS) Toxicity Mannitol injection may increase cerebral blood flow and the risk of postoperative bleeding in neurosurgical patients. Mannitol may increase cerebral blood flow and worsen intracranial hypertension in children who develop generalized cerebral hyperemia during the first 24 to 48 hours post injury.
The complications that can occur for an elevated Intracranial Pressure (ICP) patient include:
- Increased cerebral blood flow
- Risk of postoperative bleeding in neurosurgical patients
- Worsening of intracranial hypertension in children who develop generalized cerebral hyperemia during the first 24 to 48 hours post injury 2
- 3 Central Nervous System (CNS) Toxicity: Mannitol may increase cerebral blood flow and the risk of postoperative bleeding in neurosurgical patients. It may also worsen intracranial hypertension in children who develop a generalized cerebral hyperemia during the first 24 to 48 hours post injury.
These complications can also be associated with:
- CNS toxicity
- Increased risk of bleeding in neurosurgical patients
- Worsening of intracranial hypertension in certain patient populations 2
From the Research
Complications of Elevated ICP
The complications that can occur for an elevated Intracranial Pressure (ICP) patient include:
- Cerebral ischemia
- Brain herniation
- Possibly death 3 These complications can arise due to the persistent elevation of ICP, which can lead to severe and potentially life-threatening consequences.
Therapeutic Interventions and Risks
Therapeutic interventions to lower ICP include:
- Decompressive surgery
- Osmotherapy
- Hyperventilation
- Barbiturate-induced metabolic suppression
- Hypothermia 3, 4, 5 However, the treatment itself is not without risk, and the risks and benefits of medical and surgical intervention must be carefully evaluated and individualized for each patient 3.
Importance of Early Diagnosis and Treatment
Increased ICP is a neurologic emergency that requires immediate intervention 3, 6, 7. Early diagnosis and aggressive treatment of increased ICP are vital in preventing or limiting secondary brain injury in patients with a neurological insult 7. The emergency physician has a critical role to play in early identification and treatment of increased ICP 7.
Management Principles
Core management principles for patients with suspected or confirmed elevated ICP include:
- Noninvasive maneuvers
- Neuroprotective intubation and ventilation strategies
- Pharmacologic therapies such as ketamine, lidocaine, corticosteroids, and the hyperosmolar agents mannitol and hypertonic saline 6 Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure 4, 5.