• Red Flags

  1. Acutely ↓ level of consciousness

  2. Nonreactive pupil(s) (typically dilated or mid-dilated), confirmed with quantitative pupillometer if available

  3. Absence of vestibulo-ocular reflex (“doll’s eye”)

• Additional symptoms of ↑ ICP

  1. Preceding headache, nausea, vomiting

  2. Ocular motor palsies

  3. Cushing triad (late finding) — hypertension, bradycardia, apnea/bradypnea

• Herniation syndromes

  1. Uncal (medial temporal lobe)

     • Acutely ↓ level of consciousness, ipsilateral (or bilateral) fixed pupil, and contralateral (or ipsilateral) hemiparesis

  2. Subfalcine (medial frontal lobe) — ipsilateral leg weakness/hypertonia

  3. Tonsillar (inferior cerebellum) — respiratory arrest, downbeat nystagmus

• Intracranial hypertension is defined as sustained (> 5 min) elevation of ICP to > 22 mmHg

  1. As measured by ICP monitor

  2. Diagnosis should be made clinically and treatment should be initiated empirically if ICP monitor is not already in place

Appropriate for everyone with suspicion for/risk for increased ICP (interventions have minimal risk of harm)

1. Stabilize (airway, breathing, circulation)

2. Optimize venous and CSF drainage

   • elevate head of bed (≥ 30°) and maintain head/neck midline

3. Minimize CNS metabolic demand

   • Ensure adequate analgesia/sedation

   • Avoid fever — acetaminophen and physical temperature reduction methods if necessary

4. Decrease edema

   • Maintain normal sodium (Na > 135), avoid hypotonic fluids

5. Corticosteroids if appropriate to condition (see targeted interventions)

Appropriate if there is suspicion of active or impending herniation

1. Hyperosmolar therapy

   • 23.4% hypertonic saline (preferred)

     • 30 cc bolus over 10 minutes, may repeat once (total dose of 60 cc)

     • DO NOT DELAY for placement of central line — 23.4% may be given through peripheral IV

   • Mannitol

     • 0.5-1 g/kg over 5-15 minutes

     • Post-dose hypotension is common

   • Alternatives (if above unavailable)

     • 3% hypertonic saline 300-500 cc at maximal infusion rate

     • 5% NaCl, 7.5% NaCl, 8.4% NaHCO3-

   • Maintenance osmotherapy can be down with mannitol or hypertonic saline, typically to target osmolality goal or sodium goal (no consensus exists regarding appropriate goal)

2. Hyperventilation

   • At this point, most patients will have already required intubation for airway protection and/or respiratory support

   • PaCO2 goal 30-35 mmHg (roughly equivalent to ETCO2 goal 25-33 mmHg)

   • Brief (<2h) temporizing measure

3. Imaging (CT Head) will be necessary to evaluate for etiology

   • Beware: lying flat for CT will increase ICP and may accelerate herniation

   • Temporize with above measure prior to obtaining imaging

4. Neurosurgical management

   • CSF drainage via EVD (if obstructive hydrocephalus present)

     • Drain 5-10 mL CSF is EVD already in place

   • Surgical decompression or lesion resection = definitive management

Appropriate for patients with refractory ICP elevation following Tier 0 and Tier 1 measures

1. Consider higher osmolality goal

2. Deepen sedation and analgesia

   • Propofol 10-80 mcg/kg/hr — reduces cerebral metabolic rate, cerebral blood volume, and ICP

   • Fentanyl 25-200 mcg/hr — reduces ICP spikes associated with stimulus

3. Reconsider neurosurgical intervention

Appropriate for patients determined not to be surgical candidates

1. Hypothermia (32-34° C)

2. Barbiturate coma

   • Beware: pentobarbital is associated with myriad side effects and its CNS-depressant effect can take weeks to wear off (goals of care discussion recommended prior to committing to pentobarbital)

   • Requires continuous EEG

   • Pentobarbital (bolus 5–15 mg/kg over 30 min—2 h, then maintenance infusion of 1–4 mg/kg/h) titrated to ICP goal or burst suppression

• Corticosteroids

  • Only effective for vasogenic edema (tumors +/- abscess and meningitis)

    • IV dexamethasone 10-20 mg load followed by 4-6 mg q6 hours

  • Potentially harmful in other etiologies of increased ICP (TBI, infarction, hemorrhage)

• Intracranial hemorrhage — consider anticoagulant reversal

• Cerebral edema

  • Meningitis — consider IV dexamethasone 10mg q6 hours if community-acquired; LP for CSF drainage

  • Hyponatremia — correct Na <135

• Hydrocephalus — consider EVD placement for CSF drainage

• Cerebral venous sinus thrombosis (CVST) — consider IV heparin