23 - Increased Intracranial Pressure and Herniation Syndromes

Summary

Primary survey of a patient suspected of having an increased intracranial pressure (ICP) consists of a brief neurological examination and establishment of a Glasgow Coma Scale (GCS) score. Brain herniation, an end-stage manifestation of increased ICP, refers to displacement of brain tissue from one intracranial compartment to another through an opening in the dural sheath. A herniation syndrome is a neurosurgical emergency; if immediate intervention is not taken, death can ensue rapidly. Initial therapy is aimed at lowering ICP while determining and treating the underlying cause. Common conditions resulting in increased ICP include traumatic brain injury (TBI), cerebrovascular events, hydrocephalus, brain tumor, central nervous system infections, metabolic and hypoxic encephalopathies, and status epilepticus. Mannitol, an osmotic diuretic, is currently the diuretic of choice for treating increased ICP. Barbiturate therapy is effective in lowering ICP in a select subset of patients such as those with persistently high ICP despite aggressive management.