Increased Intracranial Pressure

Aka: Increased Intracranial Pressure, Elevated ICP

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II. Pathophysiology

  1. See Cerebrospinal Fluid
  2. See Cerebral Ventricle
  3. See Hydrocephalus

III. Symptoms

  1. Headache
  2. Nausea and Vomiting
  3. Limb weakness
  4. Incoordination
  5. Confusion
  6. Tinnitus

IV. Signs

  1. Infant (esp. Non-Communicating Hydrocephalus)
    1. Rapid increase in Head Circumference (>97%)
    2. Bulging Anterior Fontanelle
    3. Poor feeding
    4. Vomiting
    5. Failure to Thrive
    6. Impaired upward gaze (sunset sign)
    7. Irritability
    8. Decreased Level of Consciousness
  2. Older Children and Adults (esp. Communicating Hydrocephalus)
    1. Acute confusion
    2. Altered Level of Consciousness or somnolent
    3. Papilledema
    4. Extraocular Movement deficit
      1. Eyes displaced downward (sunset sign) or
      2. Loss of lateral gaze (Cranial Nerve 6 Palsy)
  3. Cushing Triad (severe ICP increase or impending Brainstem Herniation)
    1. Hypertension
    2. Bradycardia
    3. Irregular respirations

V. Exam

  1. Vital Signs
    1. Cushing Triad (Hypertension, Bradycardia, irregular respirations)
  2. Complete Neurologic Exam
    1. See Headache Exam
  3. Complete Eye Exam
    1. Fundoscopic Exam (Papilledema)
      1. Optic Nerve Sheath Diameter (ONSD) on POCUS >4.8-6.3 mm correlates with increased ICP
    2. Visual Field Exam
    3. Intraocular Pressure

VI. Causes

  1. See Increased Intracranial Pressure Causes
  2. See Hydrocephalus
  3. Increased Intracranial Pressure in Trauma
  4. Idiopathic Intracranial Hypertension

VII. Imaging

  1. CT Head (non-contrast)
    1. Preferred study in acutely ill patients
    2. Ventricular size (Hydrocephalus, ventriculomegaly)
    3. Obstructive lesions (e.g. CNS Mass, Subarachnoid Hemorrhage)
    4. CNS Structural abnormalities
    5. CSF Shunt malfunction
    6. Findings of Increased Intracranial Pressure
      1. Midline shift
      2. Brainstem Herniation
      3. Cerebral Ventricle or basilar cistern effacement (compressed, flattened, or obliterated)
      4. Loss of differentiation between grey and white matter
  2. MRI Brain
    1. Preferred study in Idiopathic Intracranial Hypertension and in less acutely patients, outpatient imaging
    2. Better tissue characterization than CT Head
    3. Findings of Increased Intracranial Pressure (esp. Idiopathic Intracranial Hypertension)
      1. Empty sella turcica
      2. Optic Nerve sheath distention
      3. Posterior globe flattening
      4. Transverse venous sinus stenosis
  3. Shunt Series XRays
    1. See CSF Shunt
    2. Evaluates for CSF ShuntFracture, migration, twisting or disconnection
    3. Indications
      1. CSF Shunt AND
      2. CNS Imaging is abnormal suggesting increased Hydrocephalus or Intracranial Pressure

VIII. Management: Acute, Severe Presentation

  1. See Increased Intracranial Pressure in Closed Head Injury
  2. See Ventriculoperitoneal Shunt Malfunction
  3. See Cerebral Herniation
  4. General measures to reduce Intracranial Pressure
    1. Manage pain with adequate analgesia
    2. Manage Agitation
    3. Maintain normothermia
  5. Improve cerebral venous drainage
    1. Head of bed elevated (20-35 degrees, up to 45 degrees)
      1. Promotes CNS venous drainage
    2. Avoid internal jugular compression
      1. Keep head midline
      2. Internal jugular line placement is Contraversial (some advocate Subclavian Lines instead)
  6. Endotracheal Intubation
    1. Indications
      1. See Advanced Airway for indications
      2. Airway control is in question
      3. Hypoxia or hypercarbia (adverse effects on Cerebral Perfusion Pressure)
    2. Approach
      1. Use neuroprotective strategies
        1. See Neurocritical Intubation
      2. Consider Fentanyl pretreatment (2-3 mcg/kg) to decrease sympathetic response to intubation
        1. See Rapid Sequence Induction
        2. Lidocaine in contrast is unlikely to offer pretreatment benefit
      3. Induction agents
        1. Standard agents may be used (Etomidate, Propofol or Ketamine)
        2. Although early studies suggested increased ICP with Ketamine, most subsequent studies support its safety
    3. Ventilation parameters
      1. Avoid Hyperventilation (risk of reduced cerebral perfusion due to Vasoconstriction)
  7. Blood Pressure Management
    1. Target mean arterial pressure: 80 to 110 mmHg (for adequate cerebral perfusion)
  8. Acutely lowering Intracranial Pressure (e.g. impending Brainstem Herniation)
    1. See Increased Intracranial Pressure in Closed Head Injury (similar strategies in non-Traumatic ICP increase)
    2. Mannitol 20%
      1. May dose every 4 to 6 hours
        1. Adult: 1 g/kg IV (50-100 g) bolus over 5 minutes
        2. Child: 0.25 to 0.5 g/kg IV bolus over 5 minutes
      2. Observe closely for Hypotension, especially peri-intubation (and avoid if hypotensive)
      3. Monitor Urine Output
      4. Hold manitol for Hypotension, Hypernatremia with Sodium >152 or Serum Osms >305
    3. Other measures to consider
      1. Phenobarbital Infusion
        1. Mansour (2013) J Neurosurg Pediatr 12(1):37-43 +PMID: 23641961 [PubMed]
      2. Hypertonic Saline (controversial)
        1. Dosing: 100 cc of 3% Saline
        2. Does not improve Intracranial Pressure or benefit mortality in Severe Closed Head Injury
          1. Berger-Pelleiter (2016) CJEM 18(2): 112-20 +PMID:26988719 [PubMed]
        3. Others still recommend Hypertonic Saline (consider for signs Brainstem Herniation)
          1. Expert opinion that Hypertonic Saline and manitol have equivalent efficacy
          2. Hypertonic Saline is safe, even in Hyponatremia, and without Hypotension risk
          3. Orman and Weingart in Herbert (2017) EM:Rap 17(6):8-9

IX. Management: Mild Increased ICP

  1. Indications
    1. Headache without altered LOC or focal neurologic deficit
  2. Symptomatic management of Headache
    1. See Headache Management
  3. Diagnostic evaluation
    1. May be continued outpatient (e.g. MRI imaging, opthalmology exam)

X. References

  1. Jundoria, Dave, Hoag and Lopez (2026) Crit Dec Emeg Med 40(5): 4-11

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