ICU · Neurocritical care

Acute intracranial hypertension: osmotherapy, hyperventilation, and craniectomy

Also known as Raised intracranial pressure · Intracranial hypertension · ICP management · Decompressive craniectomy · Mannitol · Hypertonic saline

Acute intracranial hypertension (ICP 22 mmHg) is life-threatening — compromises cerebral perfusion (CPP = MAP − ICP) - brain ischaemia + herniation. CAUSES: TBI, SAH, intracerebral haemorrhage, brain tumour, meningitis/encephalitis, hepatic encephalopathy, anoxia, hydrocephalus. CLINICAL (Cushing's triad — late): hypertension, bradycardia, irregular respiration. MONITORING: ICP monitor (intraventricular — EVD — gold standard; intraparenchymal — common); CPP target 60-70. MANAGEMENT ESCALATION (tiered): (1) HEAD ELEVATION 30° (neutral — lowers ICP without reducing CPP). (2) SEDATION + ANALGESIA (opiates, benzodiazepines — reduce metabolic demand + ICP). (3) NORMOVENTILATION (avoid hypercapnia - raises ICP; avoid PROLONGED hyperventilation - cerebral ischaemia). (4) OSMOTHERAPY: mannitol (20% 1 g/kg) OR hypertonic saline bolus — pulls water from brain; monitor sodium + osmolality. (5) NEUROMUSCULAR BLOCKADE (blunts stimulation-related ICP surges; evidence limited). (6) METABOLIC SUPPRESSION: pentobarbital coma titrated to burst suppression on continuous EEG (for refractory). (7) DECOMPRESSIVE CRANIECTOMY (RESCUEicp — refractory ICP 25 mmHg; trades death for severe disability). (8) TRANEXAMIC ACID within 3 h of TBI (CRASH-3). (9) HYPOTHERMIA — not indicated (Eurotherm harm). TREAT CAUSE (evacuate haematoma, drain CSF, treat infection).