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Information ⬇

Author: Michael Canty

Owing to its diverse causes (Table 72.1), raised intracranial pressure (ICP) can affect all ages and demographics. It can often present in an insidious manner with symptoms that may be difficult to differentiate from more benign pathologies. Recognition of raised ICP and urgent identification of the cause is crucial: because of the intracranial pressure-volume relationship (Box 72.1), even seemingly well, stable patients can deteriorate rapidly and without warning.

The importance of regular and reliable neurological observations should be emphasized to the nursing staff. In certain conditions, such as malignant MCA syndrome secondary to ischaemic stroke, even subtle changes to conscious level may be of critical importance and trigger urgent intervention.

Priorities ⬆ ⬇

  1. If you suspect raised intracranial pressure (Table72.2):
    • Assess the airway, breathing and circulation, and correct abnormal physiology.
    • Assess the conscious level: seek an urgent anaesthetic/intensive care opinion for patients flexing to painful stimuli or worse.
    • Arrange brain CT. Emergent or urgent CT is required in almost all cases to determine the cause of raised ICP.
    • Seek urgent advice on management from neurology or neurosurgery. Lumbar puncture may be indicated, but should only be done on specialist advice (Box 72.2).
  2. Prevent secondary brain injury
    • The cornerstone of preventing secondary brain injury is maintenance of normal physiology. Arterial oxygen and carbon dioxide tensions should be kept within normal limits. Hypo- and hypertension should be avoided. Treat fever aggressively. Maintain normal blood glucose and treat electrolyte abnormalities.
    • Nurse the patient 30° head-up to optimize cerebral venous drainage.
    • Seizures are extremely deleterious in raised ICP and should be treated aggressively. Prophylaxis is often appropriate, especially in intracranial infection – seek specialist advice.
  3. Consider therapy to reduce intracranial pressure
    • Give dexamethasone 4 mg 6-hourly IV/PO to treat tumour-related vasogenic cerebral oedema. Steroids are contraindicated in trauma. They may be used sparingly in intracranial abscess or empyema if significant mass effect is present, but only on neurosurgical advice. Always co-prescribe a proton pump inhibitor or ranitidine to prevent steroid-induced gastritis and ulceration.
    • Consider mannitol 20% 0.5–1g/kg IV to treat severely raised ICP secondary to cerebral oedema, and/or to buy time prior to neurosurgical intervention in life-threatening situations. Seek specialist advice. Mannitol must not be used in systemic hypotension. Check plasma osmolality; further doses may be given until osmolality reaches 320mosmol/kg. Beyond this, mannitol may cause rebound intracranial hypertension.

Further Management ⬆ ⬇

Further management is determined by the cause of raised ICP:

Further Reading ⬆

Bradley D, Rees J (2013) Brain tumour: mimics and chameleons. Pract Neurol 13, 359–371.

Piper RJ, Kalyvas AV, Young AMH, Hughes MA, Jamjoom AAB, Fouyas IP (2015) Interventions for idiopathic intracranial hypertension. Cochrane Database of Systematic Reviews 2015 , Issue 8. Art. No.: CD003434. DOI: 10.1002/14651858.CD003434.pub3. www.cochranelibrary.com.