Intracranial Hypertension Resident Survival Guide

Intracranial Hypertension Resident Survival Guide Microchapters

Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Sabeeh Islam, MBBS[2]

Synonyms and keywords:

## Overview

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Intracranial pressure, (ICP), is the pressure exerted by three structures inside the cranium; brain parenchyma, CSF and blood. The norma ICP is 10-15 mmHg and is usually maintained by equilibrium of the intracranial contents. Intracranial hypertension ( IH), is elevation of the pressure in the cranium. It typically occurs when the ICP is >20 mmHg. Hans Queckenstedt's was the first person to use lumbar needle for ICP monitoring. Intracranial hypertension is generally categorized as acute or chronic. The Monro-Kellie hypothesis explains the relationship between the contents of the cranium and intracranial pressure. It explains the underlying pathophysiology of elevated intracranial pressure or intracranial hypertension. Several pathophysiologic mechanisms are thought to be involved in the pathogenesis of Increased Intracaranial pressure (ICP) or Intracranial hypertension (ICH). All mechanisms eventually lead to brain injury from brain stem compression and decreased cerebral blood supply or ischemia. Increased Intracaranial pressure (ICP) or Intracranial hypertension (ICH) must be differentiated from other diseases that cause headache, nausea, vomiting and neurologic deficits such as tumor, abscess or space occupying lesion, venous sinus thrombosis, neck surgery, Obstructive hydrocephalus, meningitis, subarachnoid hemorrhage, choroid plexus papilloma, and Malignant systemic hypertension. The diagnosis of Increased Intracaranial pressure (ICP) or Intracranial hypertension (ICH) is made when ICP is >20 mmHg. CT scan or MRI may be considered initial diagnostic investigations. Intracranial hypertension is considered to be emergency condition. Treatment includes resuscitative measures and specific directed therapy. Resuscitative measures include oxygen, blood pressure and ICP monitoring, osmotic diuresis, head elevation up to 30 degrees, therapeutic hypothermia and seizure prophylaxis.

## Causes

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### Life Threatening Causes

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Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. If intracranial hypertension left untreated, may cause:

* Transtentorial herniation
* Respiratory depression
* Coma
* Brain death

### Common Causes

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* Aneurysm
* Arnold-chiari malformation
* Behçet's disease
* Brain tumor
* Cerebral edema
* Cerebral venous sinus thrombosis
* Choroid plexus tumor
* Chronic kidney disease
* Colloid cyst of third ventricle
* Contusions
* Crouzon craniofacial dysostosis
* Cushing's syndrome
* Dural arteriovenous fistula
* Encephalitis
* Epidural haemorrhage
* Epidural hematoma
* Erdheim-chester disease
* Excess cerebrospinal fluid
* Head trauma
* Hydrocephalus
* Hypertensive brain hemorrhage
* Hypertensive encephalopathy
* Idiopathic intracranial hypertension
* Intracranial granuloma
* Intracranial haemorrhage
* Intraventricular hemorrhage
* Meningioma
* Meningitis
* Meningoencephalitis
* Obstruction of superior mediastinal veins
* Obstruction of jugular veins
* Status epilepticus
* Stroke
* Subarachnoid haemorrhage
* Subdural haemorrhage
* Subdural hematoma
* Vasculitis
* Venous sinus thrombosis

## Diagnosis and Treatment

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| Signs and symptoms of Intracranial Hypertension

* Headache
* Nausea
* Vomiting
* Hyperventilation
* Ocular palsies (abducens palsy)
* Periorbital bruising
* Altered level of consciousness
* Papilledema
* Pupillary dilatation
* Cushing's triad ( Elevated systolic blood pressure, a widened pulse pressure, bradycardia, and an abnormal respiratory pattern.
* Cheyne-Stokes respiration
* Bulging of fontanels in infants

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| CT scan/MRI to rule out tumor, hematoma etc|

Monitor Intracranial pressure (ICP >20mmHg), Low Pao2, High Paco2

* Invasive ICP monitoring sites[1][2][3][4][5]
* Intraventricular[6][7]
* Intraparenchymal[8][9][10]
* Subarachnoid[5]
* Epidural[5][11]
* Noninvasive devices still need further large randomized trials to prove their clinical efficacy. They are not used in clinical practice but are still under investigation and include:[12][13]
* Transcranial Doppler (TCD)[14]
* Tissue resonance analysis (TRA)[15]
* Ocular sonography[16][17]
* Intraocular pressure[18][19]
* Tympanic membrane displacement

| Surgical evacuation if + for mass

Increased Intracranial pressure ICP>20mmHg|

[[Resuscitation[20][21][22][23][24][25][26]]]

* Maintain oxygen
* Head elevation at 30
* Hyperventilation to achieve a PaCO2 of 26-30 mmHg
* Osmotic diuresis with intravenous mannitol
* Appropriate sedation, if patient requires intubation
* Therapeutic hypothermia to achieve a low metabolic state
* Appropriate choice of fluids to achieve euvolemic state.
* Allow permissive hypertension. Treat hypertension only when CPP >120 mmHg and ICP >20 mmHg
* Seizure prophylaxis with anticonvulsant therapy

If ICP is stable and the patient is responding well to resuscitation measures

* Continue aggressive osmotic diuresis with IV mannitol and furosemide[27][28]
* Glucocorticoids when underlying etiology is brain tumor or CNS infection[29]
* Phenobarbital (Barbiturates)[30]

Persistently elevated Intracranial pressure ICP>20mmHg despite above-mentioned measures|

*Surgical evacuation

* CSF drainage via ventriculostomy
* CSF is usually drained at a rate of 1 to 2 mL/minute for 2 to 3 minutes. The procedure is repeated after every 2 to 3 minutes, until ICP is less than 20mmHg
* Decompressive craniectomy[31][32][33][34][35][36][37][38][39]

## Do's

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* Maintain oxygen
* Head elevation
* Hyperventilation to achieve a PaCO2 of 26-30 mmHg
* Osmotic diuresis with intravenous mannitol and Lasix
* Appropriate sedation, if patient requires intubation. Propofol is considered to be the preferred agent.
* Therapeutic hypothermia to achieve a low metabolic state
* Appropriate choice of fluids to achieve euvolemic state. Avoid hypotonic agents
* Allow permissive hypertension. Treat hypertension only when CPP >120 mmHg and ICP >20 mmHg
* Seizure prophylaxis with anticonvulsant therapy.

## Don'ts

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* Don't give hpyotonic fluids
* Don't aggresively treat hypertension

## References

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1. ↑ Rosner MJ, Rosner SD, Johnson AH (December 1995). "Cerebral perfusion pressure: management protocol and clinical results". J. Neurosurg. 83 (6): 949–62. doi:10.3171/jns.1995.83.6.0949. PMID 7490638.
2. ↑ Lane PL, Skoretz TG, Doig G, Girotti MJ (December 2000). "Intracranial pressure monitoring and outcomes after traumatic brain injury". Can J Surg. 43 (6): 442–8. PMC 3695200. PMID 11129833.
3. ↑ Bulger EM, Nathens AB, Rivara FP, Moore M, MacKenzie EJ, Jurkovich GJ (August 2002). "Management of severe head injury: institutional variations in care and effect on outcome". Crit. Care Med. 30 (8): 1870–6. doi:10.1097/00003246-200208000-00033. PMID 12163808.
4. ↑ Mauritz W, Steltzer H, Bauer P, Dolanski-Aghamanoukjan L, Metnitz P (July 2008). "Monitoring of intracranial pressure in patients with severe traumatic brain injury: an Austrian prospective multicenter study". Intensive Care Med. 34 (7): 1208–15. doi:10.1007/s00134-008-1079-7. PMID 18365169.
5. ↑ 5.0 5.1 5.2 Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, Manley GT, Nemecek A, Newell DW, Rosenthal G, Schouten J, Shutter L, Timmons SD, Ullman JS, Videtta W, Wilberger JE, Wright DW (2007). "Guidelines for the management of severe traumatic brain injury. VII. Intracranial pressure monitoring technology". J. Neurotrauma. 24 Suppl 1: S45–54. doi:10.1089/neu.2007.9989. PMID 17511545.
6. ↑ Mayhall CG, Archer NH, Lamb VA, Spadora AC, Baggett JW, Ward JD, Narayan RK (March 1984). "Ventriculostomy-related infections. A prospective epidemiologic study". N. Engl. J. Med. 310 (9): 553–9. doi:10.1056/NEJM198403013100903. PMID 6694707.
7. ↑ Holloway KL, Barnes T, Choi S, Bullock R, Marshall LF, Eisenberg HM, Jane JA, Ward JD, Young HF, Marmarou A (September 1996). "Ventriculostomy infections: the effect of monitoring duration and catheter exchange in 584 patients". J. Neurosurg. 85 (3): 419–24. doi:10.3171/jns.1996.85.3.0419. PMID 8751626.
8. ↑ Ostrup RC, Luerssen TG, Marshall LF, Zornow MH (August 1987). "Continuous monitoring of intracranial pressure with a miniaturized fiberoptic device". J. Neurosurg. 67 (2): 206–9. doi:10.3171/jns.1987.67.2.0206. PMID 3598682.
9. ↑ Gambardella G, d'Avella D, Tomasello F (November 1992). "Monitoring of brain tissue pressure with a fiberoptic device". Neurosurgery. 31 (5): 918–21, discussion 921–2. doi:10.1227/00006123-199211000-00014. PMID 1436417.
10. ↑ Bochicchio M, Latronico N, Zappa S, Beindorf A, Candiani A (October 1996). "Bedside burr hole for intracranial pressure monitoring performed by intensive care physicians. A 5-year experience". Intensive Care Med. 22 (10): 1070–4. doi:10.1007/BF01699230. PMID 8923072.
11. ↑ Miller JD, Bobo H, Kapp JP (August 1986). "Inaccurate pressure readings for subarachnoid bolts". Neurosurgery. 19 (2): 253–5. doi:10.1227/00006123-198608000-00012. PMID 3748354.
12. ↑ Manno EM (January 1997). "Transcranial Doppler ultrasonography in the neurocritical care unit". Crit Care Clin. 13 (1): 79–104. doi:10.1016/s0749-0704(05)70297-9. PMID 9012577.
13. ↑ Edouard AR, Vanhille E, Le Moigno S, Benhamou D, Mazoit JX (February 2005). "Non-invasive assessment of cerebral perfusion pressure in brain injured patients with moderate intracranial hypertension". Br J Anaesth. 94 (2): 216–21. doi:10.1093/bja/aei034. PMID 15591334.
14. ↑ Aaslid R, Markwalder TM, Nornes H (December 1982). "Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries". J. Neurosurg. 57 (6): 769–74. doi:10.3171/jns.1982.57.6.0769. PMID 7143059.
15. ↑ Michaeli D, Rappaport ZH (June 2002). "Tissue resonance analysis; a novel method for noninvasive monitoring of intracranial pressure. Technical note". J. Neurosurg. 96 (6): 1132–7. doi:10.3171/jns.2002.96.6.1132. PMID 12066918.
16. ↑ Moretti R, Pizzi B, Cassini F, Vivaldi N (December 2009). "Reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial hemorrhage". Neurocrit Care. 11 (3): 406–10. doi:10.1007/s12028-009-9250-8. PMID 19636971.
17. ↑ Moretti R, Pizzi B (January 2009). "Optic nerve ultrasound for detection of intracranial hypertension in intracranial hemorrhage patients: confirmation of previous findings in a different patient population". J Neurosurg Anesthesiol. 21 (1): 16–20. doi:10.1097/ANA.0b013e318185996a. PMID 19098619.
18. ↑ Sheeran P, Bland JM, Hall GM (March 2000). "Intraocular pressure changes and alterations in intracranial pressure". Lancet. 355 (9207): 899. doi:10.1016/s0140-6736(99)02768-3. PMID 10752710.
19. ↑ Han Y, McCulley TJ, Horton JC (August 2008). "No correlation between intraocular pressure and intracranial pressure". Ann. Neurol. 64 (2): 221–4. doi:10.1002/ana.21416. PMID 18570302.
20. ↑ Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F, D'Avella D, Brambilla GL, Delfini R, Servadei F, Tomei G (March 2000). "Guidelines for the treatment of adults with severe head trauma (part I). Initial assessment; evaluation and pre-hospital treatment; current criteria for hospital admission; systemic and cerebral monitoring". J Neurosurg Sci. 44 (1): 1–10. PMID 10961490.
21. ↑ Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F, D'Avella D, Brambilla GL, Delfini R, Servadei F, Tomei G (March 2000). "Guidelines for the treatment of adults with severe head trauma (part II). Criteria for medical treatment". J Neurosurg Sci. 44 (1): 11–8. PMID 10961491.
22. ↑ Davella D, Brambilla GL, Delfini R, Servadei F, Tomei G, Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F (March 2000). "Guidelines for the treatment of adults with severe head trauma (part III). Criteria for surgical treatment". J Neurosurg Sci. 44 (1): 19–24. PMID 10961492.
23. ↑ Robinson N, Clancy M (November 2001). "In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature". Emerg Med J. 18 (6): 453–7. doi:10.1136/emj.18.6.453. PMC 1725712. PMID 11696494.
24. ↑ Smith ER, Madsen JR (June 2004). "Neurosurgical aspects of critical care neurology". Semin Pediatr Neurol. 11 (2): 169–78. doi:10.1016/j.spen.2004.04.002. PMID 15259869.
25. ↑ Smith ER, Madsen JR (June 2004). "Cerebral pathophysiology and critical care neurology: basic hemodynamic principles, cerebral perfusion, and intracranial pressure". Semin Pediatr Neurol. 11 (2): 89–104. doi:10.1016/j.spen.2004.04.001. PMID 15259863.
26. ↑ Schmoker JD, Shackford SR, Wald SL, Pietropaoli JA (September 1992). "An analysis of the relationship between fluid and sodium administration and intracranial pressure after head injury". J Trauma. 33 (3): 476–81. doi:10.1097/00005373-199209000-00024. PMID 1404521.
27. ↑ Bell BA, Smith MA, Kean DM, McGhee CN, MacDonald HL, Miller JD, Barnett GH, Tocher JL, Douglas RH, Best JJ (January 1987). "Brain water measured by magnetic resonance imaging. Correlation with direct estimation and changes after mannitol and dexamethasone". Lancet. 1 (8524): 66–9. doi:10.1016/s0140-6736(87)91908-8. PMID 2879175.
28. ↑ Nath F, Galbraith S (July 1986). "The effect of mannitol on cerebral white matter water content". J. Neurosurg. 65 (1): 41–3. doi:10.3171/jns.1986.65.1.0041. PMID 3086519.
29. ↑ Roberts I, Yates D, Sandercock P, Farrell B, Wasserberg J, Lomas G, Cottingham R, Svoboda P, Brayley N, Mazairac G, Laloë V, Muñoz-Sánchez A, Arango M, Hartzenberg B, Khamis H, Yutthakasemsunt S, Komolafe E, Olldashi F, Yadav Y, Murillo-Cabezas F, Shakur H, Edwards P (2004). "Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial". Lancet. 364 (9442): 1321–8. doi:10.1016/S0140-6736(04)17188-2. PMID 15474134.
30. ↑ Marshall LF, Shapiro HM, Rauscher A, Kaufman NM (1978). "Pentobarbital therapy for intracranial hypertension in metabolic coma. Reye's syndrome". Crit. Care Med. 6 (1): 1–5. doi:10.1097/00003246-197801000-00001. PMID 639524.
31. ↑ Burkert W, Paver HD (1988). "[Decompressive trepanation in therapy refractory brain edema]". Zentralbl. Neurochir. (in German). 49 (4): 318–23. PMID 3075392.CS1 maint: Unrecognized language (link)
32. ↑ Burkert W, Plaumann H (1989). "[The value of large pressure-relieving trepanation in treatment of refractory brain edema. Animal experiment studies, initial clinical results]". Zentralbl. Neurochir. (in German). 50 (2): 106–8. PMID 2624017.CS1 maint: Unrecognized language (link)
33. ↑ Hatashita S, Hoff JT (October 1987). "The effect of craniectomy on the biomechanics of normal brain". J. Neurosurg. 67 (4): 573–8. doi:10.3171/jns.1987.67.4.0573. PMID 3655895.
34. ↑ Hatashita S, Hoff JT (January 1988). "Biomechanics of brain edema in acute cerebral ischemia in cats". Stroke. 19 (1): 91–7. doi:10.1161/01.str.19.1.91. PMID 3336907.
35. ↑ Rinaldi A, Mangiola A, Anile C, Maira G, Amante P, Ferraresi A (1990). "Hemodynamic effects of decompressive craniectomy in cold induced brain oedema". Acta Neurochir Suppl (Wien). 51: 394–6. doi:10.1007/978-3-7091-9115-6_132. PMID 2089950.
36. ↑ Gaab M, Knoblich OE, Fuhrmeister U, Pflughaupt KW, Dietrich K (1979). "Comparison of the effects of surgical decompression and resection of local edema in the therapy of experimental brain trauma. Investigation of ICP, EEG and cerebral metabolism in cats". Childs Brain. 5 (5): 484–98. doi:10.1159/000119844. PMID 477464.
37. ↑ Dam Hieu P, Sizun J, Person H, Besson G (May 1996). "The place of decompressive surgery in the treatment of uncontrollable post-traumatic intracranial hypertension in children". Childs Nerv Syst. 12 (5): 270–5. doi:10.1007/BF00261809. PMID 8737804.
38. ↑ Gower DJ, Lee KS, McWhorter JM (October 1988). "Role of subtemporal decompression in severe closed head injury". Neurosurgery. 23 (4): 417–22. doi:10.1227/00006123-198810000-00002. PMID 3200370.
39. ↑ Guerra WK, Gaab MR, Dietz H, Mueller JU, Piek J, Fritsch MJ (February 1999). "Surgical decompression for traumatic brain swelling: indications and results". J. Neurosurg. 90 (2): 187–96. doi:10.3171/jns.1999.90.2.0187. PMID 9950487.