increased intracranial pressure (ICP)
Jump to navigation
Jump to search
Etiology
- obstruction to CSF flow
- intracranial hemorrhage
- ischemic stroke
- head trauma
- CNS infections, encephalopathy
- brain tumor
- brain metastases most common malignancy-related cause[3]
- lung cancer
- cutaneous melanoma
- also associated with intracranial hemorrhage
- primary brain tumor less common malignancy-related cause
- brain metastases most common malignancy-related cause[3]
- other mass lesion (abscess, hematoma)
- hydrocephalus
- vasculitis
- pseudotumor cerebri (idiopathic intracranial hypertension)
- obstruction to venous flow
- venous sinus thrombosis
- superior vena cava syndrome
- right heart failure
- dural arteriovenous malformation with shunt
- pharmaceuticals
- endocrine disease
- idiopathic (pseudotumor cerebri)
Pathology
- any increase in intracranial pressure is not tolerated because of the fixed intracranial volume imposed by a rigid skull
- exacerbated by supine position, increased pCO2, decreased resorption of CSF[5]
Clinical manifestations
- headache
- generally 1st presenting symptom
- worse in morning[2][5]
- exacerbated by Valsalva maneuver
- nausea/vomiting
- altered mental status
- papilledema
- focal neurologic deficits
- cranial nerve 6 palsy is a false localizing sign associated with intracranial hypertension[3]
- visual changes
- dizziness
- ataxia
- Cushing's triad
- loss of consciousness
- obesity common with idiopathic intracranial hypertension
Diagnostic procedures
- ophthalmoscopy for papilledema
- lumbar puncture may indicated after mass lesion is excluded by neuroimaging
Radiology
- neuroimaging
- head CT to evaluate for mass lesions (neoplasm, intracranial bleed) midline shift or cistern effacement suggestive of increased intraranial pressure
- 10-15% of patients may be without these findings
- head CT to evaluate for mass lesions (neoplasm, intracranial bleed) midline shift or cistern effacement suggestive of increased intraranial pressure
- magnetic resonance imaging (MRI)
- better image quality
- patient in less monitored setting
- not as fast as CT
- optic nerve ultrasonography may detect intracranial hypertension at the bedside[7]
Management
- avoid obstruction to jugular venous drainage
- elevate head of bed to 30 degrees
- maintain neck & alignment
- glucocorticoid (dexamethasone)
- ventriculostomy to measure & maintain ICP < 20 mm Hg
- sedation (midazolam, propofol)
- mannitol
- initially: 0.5-1.0 mg/kg
- maintenance: 0.25-0.5 g/kg every 3-5 hours
- may be used in conjunction with diuretics
- hyperventilate to pCO2 of 30-35 torr
- induces respiratory alkalosis
- cerebral vasoconstriction
- may reduce intracranial pressure by 25-30%
- short term measure: may decrease cerebral blood flow
- maintain cerebral perfusion pressure (CPP) > 70 mm Hg
- control ICP
- maintain euvolemia
- vasopressors
- ventricular drainage for patients with hydrocephalus
- avoid hypotonic solutions (D5W, 1/2 NS)
- acetazolamide for idiopathic intracranial hypertension (pseudotumor cerebri)
- anticonvulsants:
- phenytoin 100 mg IV/NG every 8 hours for 7 days
- levetiracetam may be better
- high dose barbiturate therapy (phenobarbital)
More general terms
More specific terms
Additional terms
- cerebral perfusion pressure (CPP)
- criteria for removal of intracranial pressure (ICP) monitor
- Cushing's triad
- intracranial pressure (ICP)
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1019
- ↑ 2.0 2.1 CHS Patient Care Protocol 11/98, protocol 244-6140
- ↑ 3.0 3.1 3.2 3.3 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018.
- ↑ Eisenberg HM et al, Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank, J Neurosurg 1990, 73:688 PMID: https://www.ncbi.nlm.nih.gov/pubmed/2213158
- ↑ 5.0 5.1 5.2 Dunn LT. Raised intracranial pressure. J Neurol Neurosurg Psychiatry. 2002 Sep;73 Suppl 1:i23-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12185258
- ↑ Hoffmann J, Goadsby PJ Update on intracranial hypertension and hypotension. Curr Opin Neurol. 2013 Jun;26(3):240-7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23594732
- ↑ 7.0 7.1 Koziarz A, Sne N, Kegel F et al Bedside Optic Nerve Ultrasonography for Diagnosing Increased Intracranial Pressure: A Systematic Review and Meta-analysis. Ann Intern Med. 2019. Nov 19. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31739316 https://annals.org/aim/article-abstract/2755727/bedside-optic-nerve-ultrasonography-diagnosing-increased-intracranial-pressure-systematic-review