The Indian Journal of Pediatrics

, Volume 77, Issue 12, pp 1409–1416

Management of Raised Intracranial Pressure

  • Naveen Sankhyan
  • K. N. Vykunta Raju
  • Suvasini Sharma
  • Sheffali Gulati
Symposium on PICU protocols of AIIMS

Abstract

Appropriate management of raised intracranial pressure begins with stabilization of the patient and simultaneous assessment of the level of sensorium and the cause of raised intracranial pressure. Stabilization is initiated with securing the airway, ventilation and circulatory function. The identification of surgically remediable conditions is a priority. Emergent use of external ventricular drain or ventriculo-peritoneal shunt may be lifesaving in selected patients. In children with severe coma, signs of herniation or acutely elevated intracranial pressure, treatment should be started prior to imaging or invasive monitoring. Emergent use of hyperventilation and mannitol are life saving in such situations. Medical management involves careful use of head elevation, osmotic agents, and avoiding hypotonic fluids. Appropriate care also includes avoidance of aggravating factors. For refractory intracranial hypertension, barbiturate coma, hypothermia, or decompressive craniectomy should be considered.

Keywords

Coma Critically ill child Intracranial hypertension Traumatic brain injury 

References

  1. 1.
    Welch K. The intracranial pressure in infants. J Neurosurg. 1980;52:693–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Castillo LR, Gopinath S, Robertson CS. Management of intracranial hypertension. Neurol Clin. 2008;26:521–41.CrossRefGoogle Scholar
  3. 3.
    Mazzola CA, Adelson PD. Critical care management of head trauma in children. Crit Care Med. 2002;30:S393–401.CrossRefPubMedGoogle Scholar
  4. 4.
    Adelson PD, Bratton SL, Carney NA, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents: chapter 5. Indications for intracranial pressure monitoring in pediatric patients with severe traumatic brain injury. Pediatr Crit Care Med. 2003;4:S19–24.CrossRefPubMedGoogle Scholar
  5. 5.
    Goldstein B, Aboy M, Graham A. Neurologic monitoring. In: Nichols DG, editor. Rogers textbook of Pediatric intensive care, 4th Ed. Philadelphia: Lippincott Williams & Wilkins; 2008.Google Scholar
  6. 6.
    Marcoux KK. Management of increased intracranial pressure in critically ill child with acute neurological injury. AACN Clin Issues. 2005;16:212–31.CrossRefPubMedGoogle Scholar
  7. 7.
    Feldman Z, Kanter MJ, Robertson CS, et al. Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients. J Neurosurg. 1992;76:207–11.CrossRefPubMedGoogle Scholar
  8. 8.
    Layon JA, Gabrielli A. Elevated intracranial pressure. In: Layon JA, Gabrielli A, Friedman WA, editors. Textbook of neurointensive care. 1st ed. Pennsylvania: Saunders; 2004. p. 709–32.Google Scholar
  9. 9.
    Marsh ML, Marshall LF, Shapiro HM. Neurological intensive care. Anesthesiology. 1977;47:149–63.CrossRefPubMedGoogle Scholar
  10. 10.
    Skippen P, Seear M, Poskitt K, Kestle J, et al. Effect of hyperventilation on regional cerebral blood flow in head-injured children. Crit Care Med. 1997;25:1275–8.CrossRefGoogle Scholar
  11. 11.
    Robertson CS, Valadka AB, Hannay HJ, Contant CF, et al. Prevention of secondary ischemia insult after severe head injury. Crit Care Med. 1999;27:2086–95.CrossRefPubMedGoogle Scholar
  12. 12.
    Miller JD, Dearden NM, Piper IR, et al. Control of intracranial pressure in patients with severe head injury. J Neurotrauma. 1992;9:S317.PubMedGoogle Scholar
  13. 13.
    Kaufmann AM, Cardoso ER. Aggravation of vasogenic edema by multiple –dose mannitol. J Neurosurg. 1992;77:584–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Ziai WC, Toung TJ, Bhardwaj A. Hypertonic saline: first-line therapy for cerebral edema? J Neurol Sci. 2007;261:157–66.CrossRefPubMedGoogle Scholar
  15. 15.
    Doyle JA, Davis DP, Hoyt DB. The use of hypertonic saline in the treatment of traumatic brain injury. J Trauma. 2001;50:367–83.CrossRefPubMedGoogle Scholar
  16. 16.
    Himmelseher S. Hypertonic saline solutions for treatment of intracranial hypertension. Curr Opin Anaesthesiol. 2007;20:414–26.CrossRefPubMedGoogle Scholar
  17. 17.
    Suarez JI. Hypertonic saline for cerebral edema and elevated intracranial pressure. Cleve Clin J Med. 2004;71:S9–13.CrossRefPubMedGoogle Scholar
  18. 18.
    Strandvik GF. Hypertonic saline in critical care: a review of the literature and guidelines for use in hypotensive states and raised intracranial pressure. Anaesthesia. 2009;64:990–1003.CrossRefPubMedGoogle Scholar
  19. 19.
    Larive LL, Rhoney DH, Parker D, Coplin WM, Carhuapoma JR. Introducing hypertonic saline for cerebral edema. Neurocrit Care. 2004;1:435–40.CrossRefPubMedGoogle Scholar
  20. 20.
    Qureshi A, Suarez J, Bhardwaj A, et al. Use of hypertonic saline/acetate infusion in the treatment of cerebral edema: effect on intracranial pressure and lateral displacement of the brain. Crit Care Med. 1998;26:440–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Peterson B, Khanna S, Fischer B, Marshall L. Prolonged hypernatremia controls elevated intracranial pressure in head injured pediatric patients. Crit Care Med. 2000;28:1136–43.CrossRefPubMedGoogle Scholar
  22. 22.
    Thenuwara K, Todd MM, Brian JE, et al. Effect of mannitol and furosemide on plasma osmolality and brain water. Anesthesiology. 2002;96:416–21.CrossRefPubMedGoogle Scholar
  23. 23.
    Tornheim PA, McLaurin RL, Sawaya R. Effect of furosemide on experimental traumatic cerebral edema. Neurosurgery. 1979;4:48–52.CrossRefPubMedGoogle Scholar
  24. 24.
    Berger C, Sakowitz OW, Kiening KL, Schwab S. Neurochemical monitoring of glycerol therapy in patients with ischemic brain edema. Stroke. 2005;36:e4–6.CrossRefPubMedGoogle Scholar
  25. 25.
    French LA, Galicich JH. The use of steroids for control of cerebral edema. Clin Neurosurg. 1964;10:212–23.PubMedGoogle Scholar
  26. 26.
    Rabinstein AA. Treatment of cerebral edema. Neurologist. 2006;12:59–73.CrossRefPubMedGoogle Scholar
  27. 27.
    Edwards P, Arango M, Balica L, et al. Final results of MRCCRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury outcomes at 6 months. Lancet. 2005;365:1957–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Feigin VL, Anderson N, Rinkel GJ, Algra A, van Gijn J, Bennett DA. Corticosteroids for aneurysmal subarachnoid haemorrhage and primary intracerebral haemorrhage. Cochrane Database Syst Rev 2005; CD004583.Google Scholar
  29. 29.
    Hoffman SL, Rustama D, Punjabi NH, et al. High-dose dexamethasone in quinine-treated patients with cerebral malaria: a double-blind, placebo-controlled trial. J Infect Dis. 1988;158:325–31.PubMedGoogle Scholar
  30. 30.
    Bilitta F, Branca G, Lam A, Cuzzone V, Doronzio A, Rosa G. Endotraceal lidocaine in preventing endotracheal suctioning induced changes in cerebral hemodynamics in patients with severe head trauma. Neurocrit Care. 2008;8:241–6.CrossRefGoogle Scholar
  31. 31.
    Cochran A, Scaife ER, Hansen KW, Downey EC. Hyperglycemia and outcomes from pediatric traumatic brain injury. J Trauma. 2003;55:1035–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Biousse V, Rucker JC, Vignal C, et al. Anemia and papilledema. Am J Ophthalmol. 2003;135:437–46.CrossRefPubMedGoogle Scholar
  33. 33.
    Fortune JB, Feustal PJ, Graca L, et al. Effect of hyperventilation, mannitol, and ventriculostomy drainage on cerebral blood flow after head injury. J Trauma. 1995;39:1091–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Schalen W, Sonesson B, Messeter K, et al. Clinical outcome and cognitive impairment in patients with severe head injuries treated with barbiturate coma. Acta Neurochir (Wien). 1992;117:153–9.CrossRefGoogle Scholar
  35. 35.
    Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia therapy after traumatic brain injury in children. N Engl J Med. 2008;358:2447–56.CrossRefPubMedGoogle Scholar
  36. 36.
    Clifton GL, Miller ER, Choi SC, Levin HS, et al. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med. 2001;344:556–63.CrossRefPubMedGoogle Scholar
  37. 37.
    Adelson PD, Ragheb J, Kanev P, et al. Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery. 2005;56:740–54.CrossRefPubMedGoogle Scholar
  38. 38.
    Berger S, Schwarz M, Huth R. Hypertonic saline solution and decompressive craniectomy for treatment of intracranial hypertension in pediatric severe traumatic brain injury. J Trauma. 2002;53:558–63.CrossRefPubMedGoogle Scholar
  39. 39.
    Taylor A, Butt W, Rosenfeld J, et al. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Child’s Nerv Syst. 2001;17:154–62.CrossRefGoogle Scholar

Copyright information

© Dr. K C Chaudhuri Foundation 2010

Authors and Affiliations

  • Naveen Sankhyan
    • 1
  • K. N. Vykunta Raju
    • 1
  • Suvasini Sharma
    • 1
  • Sheffali Gulati
    • 1
  1. 1.Child Neurology Division, Department of PediatricsAll India Institute of Medical SciencesNew DelhiIndia

Personalised recommendations