Elsevier

Neurologic Clinics

Volume 26, Issue 2, May 2008, Pages 521-541
Neurologic Clinics

Management of Intracranial Hypertension

https://doi.org/10.1016/j.ncl.2008.02.003Get rights and content

Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.

Section snippets

Normal values

In normal individuals with closed cranial fontanelles, the central nervous system contents, including the brain, spinal cord, blood, and cerebrospinal fluid (CSF), are encased in a noncompliant skull and vertebral canal, constituting a nearly incompressible system. The system has a small amount of capacitance provided by the intervertebral spaces. In the average adult, the skull encloses a total volume of 1475 mL, including 1300 mL of brain, 65 mL of CSF, and 110 mL of blood [1]. The

Causes of intracranial hypertension

The different causes of intracranial hypertension (Box 1) can occur individually or in various combinations. In primary causes of increased ICP, its normalization depends on rapidly addressing the underlying brain disorder. In the second group, intracranial hypertension is due to an extracranial or systemic process that is often remediable [9], [10], [11]. The last group comprises the causes of increased ICP after a neurosurgical procedure.

Intracranial hypertension secondary to traumatic brain injury

Special features should be considered in patients who

Neurologic intensive care monitoring

Intracranial hypertension is an important cause of secondary injury in patients who have acute neurologic and neurosurgical disorders and typically mandates specific monitoring. Patients who have suspected intracranial hypertension, especially secondary to TBI, should have monitoring of ICP; monitoring of cerebral oxygen extraction, as with jugular bulb oximetry or brain tissue Po2, may also be indicated. Brain-injured patients should also have close monitoring of systemic parameters, including

Intracranial pressure monitoring

Clinical symptoms of increased ICP, such as headache, nausea, and vomiting, are impossible to elicit in comatose patients. Papilledema is a reliable sign of intracranial hypertension, but is uncommon after head injury, even in patients who have documented elevated ICP. In a study of patients who had head trauma, 54% of patients had increased ICP, but only 3.5% had papilledema on fundoscopic examination [18]. Other signs, such as pupillary dilation and decerebrate posturing, can occur in the

Intracranial pressure treatment measures: brief summary of goals of therapy

The goals of ICP treatment may be summarized as follows:

  • 1.

    Maintain ICP at less than 20 to 25 mm Hg.

  • 2.

    Maintain CPP at greater than 60 mm Hg by maintaining adequate MAP.

  • 3.

    Avoid factors that aggravate or precipitate elevated ICP.

An overall approach to the management of intracranial hypertension is presented in Fig. 1.

General care to minimize intracranial hypertension

Prevention or treatment of factors that may aggravate or precipitate intracranial hypertension is a cornerstone of neurologic critical care. Specific factors that may aggravate intracranial hypertension include obstruction of venous return (head position, agitation), respiratory problems (airway obstruction, hypoxia, hypercapnia), fever, severe hypertension, hyponatremia, anemia, and seizures.

Measures for refractory intracranial hypertension

For patients who have sustained ICP elevations of greater than 20 to 25 mm Hg, additional measures are needed to control the ICP. Emergent surgical management should be considered whenever intracranial hypertension occurs suddenly or is refractory to medical management.

Heavy sedation and paralysis

Routine paralysis of patients who have neurosurgical disorders is not indicated; however, intracranial hypertension caused by agitation, posturing, or coughing can be prevented by sedation and nondepolarizing muscle relaxants that do not alter cerebrovascular resistance [45]. A commonly used regimen is morphine and lorazepam for analgesia/sedation and cisatracurium or vecuronium as a muscle relaxant, with the dose titrated by twitch response to stimulation. A disadvantage of this therapy is

Resection of mass lesions

Intracranial masses producing elevated ICP should be removed when possible. Acute epidural and subdural hematomas are a hyperacute surgical emergency, especially epidural hematoma because the bleeding is under arterial pressure. Brain abscess must be drained, and pneumocephalus must be evacuated if it is under sufficient tension to increase ICP. Surgical management of spontaneous intracerebral bleeding is controversial [77].

Cerebrospinal fluid drainage

CSF drainage lowers ICP immediately by reducing intracranial volume,

Summary

Effective treatment of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased ICP. When ICP becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased ICP should include sedation, drainage of CSF, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or

References (87)

  • M.J. Rosner et al.

    Cerebral perfusion pressure, intracranial pressure, and head elevation

    J Neurosurg

    (1986)
  • W. Gobiet et al.

    The relation between intracranial pressure, mean arterial pressure and cerebral blood flow in patients with severe head injury

    Acta Neurochir (Wien)

    (1975)
  • D.I. Friedman

    Medication-induced intracranial hypertension in dermatology

    Am J Clin Dermatol

    (2005)
  • S. Jacob et al.

    Intracranial hypertension induced by rofecoxib

    Headache

    (2005)
  • K. Digre et al.

    Is vitamin A implicated in the pathophysiology of increased intracranial pressure?

    Neurology

    (2005)
  • P.D. Adelson et al.

    Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents: chapter 5. Indications for intracranial pressure monitoring in pediatric patients with severe traumatic brain injury

    Pediatr Crit Care Med

    (2003)
  • B. Asgeirsson et al.

    A new therapy of post-trauma brain oedema based on haemodynamic principles for brain volume regulation

    Intensive Care Med

    (1994)
  • D.A. Bruce et al.

    Diffuse cerebral swelling following head injuries in children: the syndrome of “malignant brain edema.”

    J Neurosurg

    (1981)
  • A. Marmarou et al.

    Contribution of edema and cerebral blood volume to traumatic brain swelling in head-injured patients

    J Neurosurg

    (2000)
  • A. Unterberg et al.

    Long-term observations of intracranial pressure after severe head injury: the phenomenon of secondary rise of intracranial pressure

    Neurosurgery

    (1993)
  • M. Taneda et al.

    Traumatic subarachnoid hemorrhage as a predictable indicator of delayed ischemic symptoms

    J Neurosurg

    (1996)
  • J.B. Selhorst et al.

    Papilledema after acute head injury

    Neurosurgery

    (1985)
  • P.R. Kishore et al.

    Significance of CT in head injury: correlation with intracranial pressure

    AJR Am J Roentgenol

    (1981)
  • P.D. Adelson et al.

    Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents: chapter 7. Intracranial pressure monitoring technology

    Pediatr Crit Care Med

    (2003)
  • S.P. Gopinath et al.

    Clinical evaluation of a miniature strain-gauge transducer for monitoring intracranial pressure

    Neurosurgery

    (1995)
  • M. Czosnyka et al.

    Laboratory testing of three intracranial pressure microtransducers: technical report

    Neurosurgery

    (1996)
  • N. Lundberg

    Continuous recording and control of ventricular fluid pressure in neurosurgical practice

    Acta Psychiatr Scand

    (1960)
  • M.G. O'Sullivan et al.

    Role of intracranial pressure monitoring in severely head-injured patients without signs of intracranial hypertension on initial computerized tomography

    J Neurosurg

    (1994)
  • C.G. Mayhall et al.

    Ventriculostomy-related infections: a prospective epidemiologic study

    N Engl J Med

    (1984)
  • K.L. Holloway et al.

    Ventriculostomy infections: the effect of monitoring duration and catheter exchange in 584 patients

    J Neurosurg

    (1996)
  • P. Park et al.

    Risk of infection with prolonged ventricular catheterization

    Neurosurgery

    (2004)
  • J.M. Zabramski et al.

    Efficacy of antimicrobial-impregnated external ventricular drain catheters: a prospective, randomized, controlled trial

    J Neurosurg

    (2003)
  • Z. Feldman et al.

    Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients

    J Neurosurg

    (1992)
  • I. Ng et al.

    Effects of head posture on cerebral hemodynamics: its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation

    Neurosurgery

    (2004)
  • D.K. Joseph et al.

    Decompressive laparotomy to treat intractable intracranial hypertension after traumatic brain injury

    J Trauma

    (2004)
  • J.B. North et al.

    Abnormal breathing patterns associated with acute brain damage

    Arch Neurol

    (1974)
  • J.D. Miller et al.

    Secondary insults to the injured brain

    J R Coll Surg Edinb

    (1982)
  • A. Caricato et al.

    Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance

    J Trauma

    (2005)
  • J. Albanese et al.

    Sufentanil, fentanyl, and alfentanil in head trauma patients: a study on cerebral hemodynamics

    Crit Care Med

    (1999)
  • W.D. Dietrich et al.

    Delayed posttraumatic brain hyperthermia worsens outcome after fluid percussion brain injury: a light and electron microscopic study in rats

    Neurosurgery

    (1996)
  • P.A. Jones et al.

    Measuring the burden of secondary insults in head-injured patients during intensive care

    J Neurosurg Anesthesiol

    (1994)
  • C.S. Robertson et al.

    Treatment of hypertension associated with head injury

    J Neurosurg

    (1983)
  • P.C. Hebert et al.

    A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group

    N Engl J Med

    (1999)
  • Cited by (279)

    View all citing articles on Scopus

    This article was supported by National Institutes of Health grant P01-NS38660.

    This is an updated version of an article that originally appeared in Critical Care Clinics, volume 22, issue 4.

    View full text