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    Increased ICP


    Last Updated Jan 23, 2024
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    First 5 Minutes

    Signs of brain herniation suggestive of severely elevated ICP warrants rapid treatment.


    • Cerebral perfusion pressure (CPP) can be conceptualized as the difference between the mean arterial pressure (MAP) and intracranial pressure (ICP).
    • Elevation in ICP can result in reductions in CPP, leading to brain ischemia.
    • Normal intracranial pressure is < 20 mm Hg.
    • As the cranium is a fixed, rigid space, increases in volume within the cranial cavity results in increased ICP after compensatory mechanisms are exceeded.
    • Elevated ICP can has various etiologies and can be broken down into:
      • Mass effect (blood, abscess, tumour)
      • Increased CSF
      • Decreased CSF resorption
      • Increased blood volume

    Diagnostic Process

    • Elevated ICP should be suspected based on mechanism of injury, history and physical.
    • Physical examination consistent with increased ICP including unilateral or bilaterally fixed, dilated pupils, decorticate or decerebrate posturing, and papilledema.
    • Severe cases may present with Cushing’s triad: bradycardia, hypertension, and irregular respirations.
    • Imaging with CT of the head (or MRI) can reveal signs of raised ICP and should be completed on all patients with suspected elevated ICP.
    • The diagnosis of increased ICP is generally based on clinical findings and imaging, but in certain cases invasive ICP monitoring may be warranted for more close monitoring of ICP.

    Recommended Treatment

    • Treatment should be focussed on relieving the underlying cause, such as evacuation of underlying hematoma or treatment of intracranial infection.
    • Medical management:
      • Head of bed elevation to 30 degrees.
      • BP should be controlled to maintain cerebral perfusion pressure >60 mm Hg.
      • Avoid hypoxemia keeping PaO2 >60 mm Hg.
      • Sedation should be utilized to reduce metabolic demand. Propofol is most commonly used and titrated to desired effect 0-80 mcg/kg/min.
      • Osmotic therapy with either hypertonic saline to target Na 140-150 mEq/L, or mannitol bolused at 1g/kg with repeat doses at 0.25 g/kg to 0.5 g/kg as required.
      • Antipyretics and cooling devices should be used to maintain temperature between 36 -37.5 Celsius.
    • Surgical management:
      • External ventricular drain (EVD) can be placed to monitor ICP as well as drain CSF to reduce ICP.
      • Decompressive craniectomy may need to be performed in cases of severely elevated ICP with signs of herniation.

    Criteria For Hospital Admission

    • All patients with elevated ICP secondary to trauma should be admitted to hospital, as well as any patient with a GCS less than 15.
    • Discharge with outpatient management may be appropriate in more benign causes of increased ICP such as idiopathic intracranial hypertension.

    Criteria For Transfer To Another Facility

    • Patients with elevated ICP and changes in mental status should be transferred to centres with intensive care capabilities and neurosurgical specialists.
    • Airway control with intubation should be considered prior to transport in all patients with reduced GCS.

    Criteria For Close Observation And/or Consult

    • Patients with acute elevations in ICP should be observed and managed in an intensive care setting.
    • Those with chronic elevations in ICP may be suitable for outpatient management depending on etiology.

    Criteria For Safe Discharge Home

    Generally not applicable.

    Quality Of Evidence?


    Recommendations are based on information from systematic reviews on management of moderate and severe traumatic brain injuries and elevated intracranial pressure.


    Related Information


    Reference List

    1. Pinto VL, Tadi P, Adeyinka A. Increased Intracranial Pressure. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Dec 26]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK482119/

    2. Ragland J, Lee K. Critical Care Management and Monitoring of Intracranial Pressure. J Neurocrit Care. 2016 Dec 28;9(2):105–12.

    3. Freeman WD. Management of Intracranial Pressure. Continuum (Minneap Minn). 2015 Oct;21(5 Neurocritical Care):1299–323.

    4. Evaluation and management of elevated intracranial pressure in adults – UpToDate [Internet]. [cited 2023 Dec 26]. Available from: https://www.uptodate.com/contents/evaluation-and-management-of-elevated-intracranial-pressure-in-adults?search=increased%20intracranial%20pressure&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H20


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