Management of Intracranial Hypertension in Head Injury: Matching Treatment with Cause

  • J. Douglas Miller
  • I. R. Piper
  • N. M. Dearden
Part of the Acta Neurochirurgica book series (NEUROCHIRURGICA, volume 57)


Raised intracranial pressure (ICP) is common after head injury and strongly associated with mortality and morbidity. Empirical and prophylactic therapy with steroids and barbiturates has proved unsuccessful. Ideally, therapy should be targeted at the predominant cause of the increase in ICP. In head injury these may be
  1. (1)

    an increase in cerebral blood volume best treated by hyperventilation and hypnotic drugs,

  2. (2)

    an increase in brain water content best treated by osmotherapy and

  3. (3)

    increased CSF outflow resistance best treated by CSF drainage. This last cause seldom predominates in head injury.


To determine whether it is possible to identify the best therapy in individual head injured patients, we are comparing osmotherapy (mannitol) and hypnotic drugs (thiopentone and gamma-hydroxybutyrate) in selected patients with severe head injury where it is possible to maintain standard conditions of ventilation and stable blood pressure and to measure ICP, CPP, brain electrical activity, PR ratio of the ICP wave form and cerebral AvDO2 before and during each of the two forms of therapy. Effective therapy means that ICP has been reduced to 20 mm Hg with preservation or improvement in CPP.

17 patients have been studied so far and 4 groups identified. Osmotherapy was superior to hypnotic in 5 cases, hypnotic superior to mannitol in 3 cases, both were effective in 5 cases and neither effective in 4 cases. Patients in whom hypnotics were superior tended to be younger, with diffuse rather than focal brain injury, had the highest levels of brain electrical activity prior to treatment and a higher PR ratio. During successful therapy AvDO2 decreased and patients made a good recovery suggesting that in the patients who responded best to hypnotic drugs the primary brain damage was not severe.


Head injury intracranial hypertension cerebral monitoring osmotherapy and hypnotics 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    BeckerDP, Vries JK (1972) The alleviation of increased intracranial pressure by thechronic administration of osmotic agents. In: Brock M, Dietz H (eds)Intracranial pressure. Springer, Berlin Heidelberg New York, pp 309–315CrossRefGoogle Scholar
  2. 2.
    Becker DP, MillerJD, Ward JD, Greenberg RP, Young HF, Sakalas R (1977) The outcome from severehead injury with early diagnosis and intensive management. J Neurosurg 47:491–502PubMedCrossRefGoogle Scholar
  3. 3.
    Bell BA, SmithMA, Kean DM, MacDonald HL, Barnett GH, Douglas RHB, Smith MA, McGhee CNJ,Miller JD, Tocker JL, Best JJK (1987) Brain water measured by magneticresonance imaging: correlation with direct estimation and change followingmannitol and dexamethasone. Lancet 1: 66–69PubMedCrossRefGoogle Scholar
  4. 4.
    Bingham RM,Procaccio F, Prior PF, Hinds CJ (1985) Cerebral electrical activity influencesthe effects of etomidate on cerebral perfusion pressure in traumatic coma. Br JAnaesth 57: 843–848CrossRefGoogle Scholar
  5. 5.
    Braakman R,Schouten HJA, Blauw-van Dishoeck M,Minderhoud JM (1983) Megadose steroids in severe head injury: results of aprospective double-blind clinical trial. J Neurosurg 58: 326–330PubMedCrossRefGoogle Scholar
  6. 6.
    Bray RS, SherwoodAM, Halter JA,RobertsonC, Grossman RG (1986) Development of a clinical monitoring system by means ofICP waveform analysis. In: Miller JD, Teasdale GM, Rowan JO, et al(eds)Intracranial pressure VI. Springer, Berlin Heidelberg New York, pp 260–264Google Scholar
  7. 7.
    Brock M, WiegandH, Zillig C, Zywietz C, Mock P, Dietz H (1976) The effect of dexamethasone onintracranial pressure in patients with supratentorial tumors. In: Pappius HM, Feindel W (eds)Dynamics of brain edema. Springer, Berlin Heidelberg New York, pp 330–336CrossRefGoogle Scholar
  8. 8.
    Cooper PR, MoodyS, Clark WK, Kirkpatrick J, Maravilla K, Gould AL, Drane W (1979)Dexamethasone and severe head injury: a prospective double-blind study. JNeurosurg 51: 307–316CrossRefGoogle Scholar
  9. 9.
    Dearden NM,Gibson JS, McDowall DG, Gibson RM, Cameron MM (1986) Effect of high dosedexamethasone on outcome from severe head injury. J Neurosurg 64: 81–88PubMedCrossRefGoogle Scholar
  10. 10.
    Dearden NM,Miller JD (1989) Paired comparison of hypnotic and osmotic therapy in thereduction of intracranial hypertension after head injury. In: Hoff JT, Betz AL (eds)Intracranial pressure VII. Springer, Berlin Heidelberg New York, pp 471–481Google Scholar
  11. 11.
    DeSalles AAF,Muizelaar JP, Young HF (1987) Hyperglycemia, cerebrospinal fluid lactate andcerebral blood flow in severely head injured patients. Neurosurgery 21: 45–50CrossRefGoogle Scholar
  12. 12.
    EisenbergHM, FrankowskiRF, Contant CF, Marshall LM, Walker MD and the Comprehensive Central NervousSystem Trauma Centers (1988) High dose barbiturate control of elevatedintracranial pressure in patients with severe head injury. J Neurosurg 69:15–23PubMedCrossRefGoogle Scholar
  13. 13.
    Faupel G, ReulenHJ, MüllerD, SchürmannK(1976) Double blind study on the effects of steroids on severe closed headinjury. In: Pappius HM, Feindel W (eds) Dynamics of brain edema. Springer,Berlin Heidelberg New York, pp 337–343CrossRefGoogle Scholar
  14. 14.
    Gobiet W, Bock WJ, LiesegangJ,Grote W (1976) Treatment of acute cerebral edema with high dose ofdexamethasone. In: Beks JWF, Bosch DA, Brock M (eds) Intracranial pressure III,Springer, Berlin Heidelberg New York, pp 231–235CrossRefGoogle Scholar
  15. 15.
    Gudeman SK,Miller JD, Becker DP (1979) Failure of high dose steroid therapy to influenceintracranial pressure in patients with severe head injury. J Neurosurg 51:301–306PubMedCrossRefGoogle Scholar
  16. 16.
    Leggate JRS, Dearden NM,Miller JD (1986) The effects of gammahydroxybutyrate and sodium thiopentone onintracranial pressure in severe head injury. In: Miller JD, Teasdale GM, RowanJO, et al(eds)Intracranial pressure VI. Springer, Berlin Heidelberg New York, pp 754–757Google Scholar
  17. 17.
    Lundberg N (1960)Continuous recording and control of ventricular fluid pressure in neurosurgicalpractice. Acta Phychiatr Neurol Scand 36 [Suppl 149]: 1–193Google Scholar
  18. 18.
    Miller JD (1979)Clinical management of cerebral oedema. Br JHospMed 20: 152–166Google Scholar
  19. 19.
    Miller JD,Ledingham IM(1971)Reduction of increased intracranial pressure: comparison between hyperbaricoxygen and hyperventilation. Arch Neurol 24: 210–216PubMedCrossRefGoogle Scholar
  20. 20.
    Miller JD, LeechPJ (1975) Assessing the effects of mannitol and steroid therapy on intracranialvolume/pressure relationships. J Neurosurg 42: 274–281PubMedCrossRefGoogle Scholar
  21. 21.
    Miller JD, BeckerDP, Ward JD, Sullivan HG, Adams WE, Rosner MJ (1977) Significance ofintracranial hypertension in severe head injury. J Neurosurg 47: 503–516PubMedCrossRefGoogle Scholar
  22. 22.
    Miller JD,Sakalas R, Ward JD (1977) Methylprednisolone treatment in patients with braintumors. Neurosurgery 1: 114– 117PubMedCrossRefGoogle Scholar
  23. 23.
    Miller JD,Butterworth JF, Gudeman SK, Faulkner JE, Choi SC, Selhorst JB, Harbison JW,LutzHA,Young HF, Becker DP (1981) Further experience in the management of severe headinjury. J Neurosurg 54: 289–299PubMedCrossRefGoogle Scholar
  24. 24.
    Muizelaar JP, Lutz HA, Becker DP(1984) Effect of mannitol on ICP and CBF and correlation with pressureautoregulation in severely head injured patients. J Neurosurg 61: 700–706PubMedCrossRefGoogle Scholar
  25. 25.
    Muizelaar JP, vanderPoelHG, Li Z, KontosHA, LevasseurJE(1988)Pial arteriolar diameter and CO2 reactivity during prolonged hyperventilationin the rabbit. J Neurosurg 69: 923–927PubMedCrossRefGoogle Scholar
  26. 26.
    Muizelaar JP, WeiEP,Kontos HA,Becker DP (1983) Mannitol causes compensatory cerebral vasoconstriction andvasodilatation to blood viscosity changes. J Neurosurg 59: 822–828PubMedCrossRefGoogle Scholar
  27. 27.
    Nordström CH, Messeter R, Sundbarg G, Schalin W, Werner M,Ryding E (1988) Cerebral blood flow, vasoreactivity and oxygen consumptionduring barbiturate therapy in severe traumatic brain lesions. J Neurosurg 68:424–431PubMedCrossRefGoogle Scholar
  28. 28.
    Pappius HM, Dayes LA (1965) Hypertonieurea:its effect on the distribution of water and electrolytes in normal andedematous brain tissues. Arch Neurol 13: 395–402PubMedCrossRefGoogle Scholar
  29. 29.
    Piper IR, DeardenNM, Miller JD (1989) Can waveform analysis of ICP separate vascular fromnon-vascular causes of intracranial hypertension? In: Hoff JT, Betz AL (eds)Intracranial pressure VII. Springer, Berlin Heidelberg New York, pp 157–163CrossRefGoogle Scholar
  30. 30.
    Pitts LH, KaktisJV (1980) Effect of megadose steroids on ICP in traumatic coma. In: Shulman K,Marmarou A, Miller JD, ei al(eds) Intracranial pressure IV. Springer,Berlin Heidelberg New York, pp 638–642CrossRefGoogle Scholar
  31. 31.
    Rockoff MA,Marshall LF, Shapiro HM (1979) High-dose barbiturate therapy in man: a clinicalreview of sixty patients. Ann Neurol 6: 194–199PubMedCrossRefGoogle Scholar
  32. 32.
    Rosner MJ, Coley I(1987) Cerebral perfusion pressure: a hemodynamic mechanism of mannitol and thepre-mannitol hemnçrramNeurosurperv 21: 147– 156CrossRefGoogle Scholar
  33. 33.
    Saul TG, DuckerTB, Salcman M, Cairo E (1981) Steroids in severe head injury: a prospectiverandomised clinical trial. J Neurosurg 54: 596–600PubMedCrossRefGoogle Scholar
  34. 34.
    Schwartz ML,Tator CH, Rowed DW (1984) The University of Toronto head injury treatmentstudy: a prospective randomised comparison of pentobarbital and mannitol. CanadJ Neurol Sci11:434–440Google Scholar
  35. 35.
    Takagi H, SaitoT, Kitahara T, Morii S, Ohwada T, Yada K (1983) The mechanism of theICP-reducing effect of mannitol. In: Ishii S, Nagai H, Brock M (eds)Intracranial pressure V. Springer, Berlin Heidelberg New York, pp 729–733CrossRefGoogle Scholar
  36. 36.
    Ward JD, BeckerDP, Miller JD, Choi SC, Marmarou A, Wood C, Newlon PG, Keenan R (1985) Failureof prophylactic barbiturate coma in the treatment of severe head injury. JNeurosurg 62: 383–388CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 1993

Authors and Affiliations

  • J. Douglas Miller
    • 1
  • I. R. Piper
    • 1
  • N. M. Dearden
    • 1
  1. 1.Department of Clinical NeurosciencesUniversity of EdinburghScotland, UK

Personalised recommendations