Abstract
Intracranial hypertension (IH) is a common and significant secondary insult in patients with acute neurologic injury. Clinical signs in patients with altered level of consciousness poorly predict IH, except in advanced stages. Head computed tomography (CT) scans are the initial examination in these patients since it can detect structural causes for IH and provides surgery indication. Optic nerve sheath ultrasound has good accuracy for detecting IH and can be useful as a triage tool in some settings.
While it is possible to treat IH with noninvasive tools, invasive monitoring of intracranial pressure (ICP) is the gold standard. A threshold for treatment of IH above 22 mmHg has been established in the Brain Trauma Foundation Guidelines. The two fundamental principles to treat IH are surgical treatment if indicated as soon as possible and to correct anatomic and physiologic derangements that worsen cerebral edema. To correct these anatomic factors, the head of the bed should be elevated and attention should be paid to neck position, avoiding jugular compression. The main goals of physiological variables are normal arterial oxygen and carbon dioxide partial pressures, mean cerebral perfusion pressure 60–70 mmHg (or individualized according to IH response), avoiding hyperthermia, anemia, and hypoglycemia.
If IH persists after these fundamental principles were applicable, sequential stepwise therapies are suggested. They are generally ordered according to the magnitude of collateral effects since they can be lifesaving but none of them are innocuous: cerebrospinal fluid drainage, optimizing sedation, hyperosmolar therapy, induced hypocapnia, metabolic suppression with barbiturates, mild hypothermia, and decompressive craniectomy.
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Appendices
Algorithm 1 – For Patients Without ICP Monitoring
Algorithm 2 – For Patients with ICP Monitoring
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Bassi, E., Tomazini, B.M., Cadamuro, F.M., Roepke, R.M.L., Carneiro, B.V., Malbouisson, L.M.S. (2021). Management of Intracranial Hypertension. In: Figueiredo, E.G., Welling, L.C., Rabelo, N.N. (eds) Neurocritical Care for Neurosurgeons. Springer, Cham. https://doi.org/10.1007/978-3-030-66572-2_12
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