ICU · neurocritical care
Acute Raised Intracranial Pressure and Traumatic Brain Injury — Comprehensive Neurocritical Care
Also known as Raised intracranial pressure (ICP) · Intracranial hypertension · Traumatic brain injury (TBI) · Severe head injury · Cerebral perfusion pressure (CPP) · Decompressive craniectomy · Monro-Kellie doctrine · Brain herniation · Osmotherapy (mannitol, hypertonic saline) · Brain Trauma Foundation guidelines · RESCUEicp · Secondary brain injury
Comprehensive severe TBI care: osmotherapy choice and ceilings, hyperventilation boundaries, barbiturates, late versus early craniectomy, secondary insults, phenytoin timing, monitoring debates and prognostication.
Checked against its sources on 13 Oct 2026
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Red flags
- ICP >22 mmHg REQUIRES treatment — every mmHg above 22 increases mortality (Brain Trauma Foundation 4th edition threshold).
- CPP = MAP − ICP — target 60-70 mmHg. CPP <60 → cerebral ischaemia; CPP >70 → ARDS risk (BEST:TRIP).
- Cushing's triad (hypertension + bradycardia + irregular respiration) = LATE, PRE-TERMINAL sign — brainstem herniation is IMMINENT. Do not wait for it to act.
- AVOID prophylactic hyperventilation (PaCO2 <35), especially in the first 24 h — cerebral ischaemia. Short-term hyperventilation (PaCO2 30-35) is acceptable ONLY as a bridge during an acute herniation crisis.
- AVOID hypotension (SBP <110 DOUBLES mortality) and hypoxia (SpO2 <90 TRIPLES mortality) — a SINGLE episode of each worsens neurological outcome.
- STEROIDS ARE CONTRAINDICATED in TBI — the CRASH trial showed increased mortality. Do not give dexamethasone for head injury.
- Mannitol: monitor serum osmolarity (keep <320 mOsm/L — above → AKI) and check it is not hypovolaemic before giving (maintain intravascular volume).
- Decompressive craniectomy (RESCUEicp) reduces mortality but increases vegetative/severely-disabled survivors — a 'troubling trade-off' that MUST be discussed with family before surgery.
A ventilated severe TBI patient has a rising ICP despite sedation and CSF drainage. This topic is the comprehensive-ICU twin: it answers the osmotherapy choice, the hyperventilation boundaries and the last-tier options in trial detail, complementing the base leaf's tier structure.[6]
Osmotherapy — the evidence in detail
Mannitol versus hypertonic saline — what the sources carry
[9]
[17]
[18]
[20]
[20]
[19]
| Question | Evidence |
|---|---|
| Which is the cornerstone? | Hyperosmolar therapy (mannitol or hypertonic saline) is the cornerstone of medical treatment of acute intracranial hypertension |
| Is there an optimal HTS dose? | No consensus on the optimal therapeutic dose and concentration of hypertonic saline |
| 23.4% saline 30 mL vs mannitol 0.5 g/kg | No significant difference in absolute ICP reduction at 60 minutes (31 patients, 162 doses) |
| Bolus vs continuous HTS | Continuous reached goal osmolality more often (93.9% vs 73.3%) and stayed at goal more (80% vs 50%); but more hyperchloraemia and AKI (0% vs 12.9%) |
| Osmolality ceiling | 320 mOsm/kg H2O seems the maximum; above 310 may already induce cardiac and immune disorders |
| Mannitol monitoring | Stop when osmolality reaches 320; guide by 12-hourly measurement; 33% of occasions exceeded the desired value |
In children with severe TBI, bolus hypertonic saline associated with lower ICP and higher CPP, mannitol only with higher CPP — in the comparative study already covered.[23]
Cottrell — mannitol monitoring in practice
Protocol
100 mL of 20% mannitol three times daily as bolus over 20-30 minutes; osmolality 12-hourly
Result
On 33% of occasions osmolality exceeded 320 — the fixed protocol was perhaps excessive beyond 48 hours
Rule
Guide by 12-hourly osmolality; limit to 48 hours without measurement facilities
References25ShowHide
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- [2]Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. The New England journal of medicine, 2016.PMID 27602507
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- [12]CRASH-3 trial collaborators Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet (London, England), 2019.PMID 31623894
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- [19]Sharma RM, Setlur R, Swamy MN Evaluation of mannitol as an osmotherapeutic agent in traumatic brain injuries by measuring serum osmolality. Medical journal, Armed Forces India, 2011.PMID 27365811
- [20]Dabrowski W, Siwicka-Gieroba D, Robba C, et al. Potentially Detrimental Effects of Hyperosmolality in Patients Treated for Traumatic Brain Injury. Journal of clinical medicine, 2021.PMID 34575255
- [21]Holden DN, Mucksavage JJ, Cokley JA, et al. Hypertonic saline use in neurocritical care for treating cerebral edema: A review of optimal formulation, dosing, safety, administration and storage. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 2023.PMID 36480317
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- [23]Kochanek PM, Adelson PD, Rosario BL, et al. Comparison of Intracranial Pressure Measurements Before and After Hypertonic Saline or Mannitol Treatment in Children With Severe Traumatic Brain Injury. JAMA network open, 2022.PMID 35267036
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