Management of Intracranial Hypertension

The goal for patients presenting with raised ICP is to identify and address the underlying
cause along with measures to reduce ICP (Fig. 1, Table 3). It is important not to delay
treatment, in situations where identifying the underlying cause will take time. When elevated
ICP is clinically evident, the
situation is urgent and requires immediate reduction in ICP. Avoidance of factors aggravating
or precipitating raised ICP is an important goal for all children with intracranial hypertension.
The availability of ICP monitors is not universal

ABCs
The assessment and management of the airway, breathing and circulation (ABCs) is the
beginning point of management. Early endotracheal intubation should be considered for those
children with GCS <8, evidence of herniation, apnea or have inability to maintain airway.
Intubation should proceed with administration of medications to blunt the ICP during the
procedure. Suggested medications are lidocaine, thiopental and a short-acting non
depolarizing neuromuscular blockade agent (e.g.vecuronium, atracurium) [6]. Appropriate
oxygenation should be ensured. If there is evidence of circulatory failure, fluid bolus should
be given. Samples should be drawn for investigations as suggested by history.

Positioning
Mild head elevation of 15–30° has been shown to reduce ICP with no significant detrimental
effects on CPP or
CBF [7]. The child’s head is positioned midline with the head end of the bed elevated to 15–
30° to encourage jugular venous drainage [7]. Sharp head angulations and tight neck
garments or taping should be avoided [8]. One has to ensure that the child is euvolemic and
not in shock prior to placing in this position [6].

Hyperventilation
Decreasing the PaCO2 to the range of 30–35 mm of Hg, is an effective and rapid means to
reduce ICP [6, 9]. Hyperventilation acts by constriction of cerebral blood vessels and
lowering of CBF. This vasoconstrictive effect on cerebral arterioles lasts only 11 to 20 h
because the pH of the CSF rapidly equilibrates to the new PaCO2 level. Moreover, aggressive
hyperventilation can dramatically decreases the CBF, causing or aggravating cerebral
ischemia [10, 11]. Hence, the most effective use of hyperventilation is for acute, sharp
increases in ICP or signs of impending herniation [12].

Osmotherapy

Mannitol
Mannitol has been the cornerstone of osmotherapy in raised ICP. However, the optimal
dosing of mannitol is not known. A reasonable approach is to use an initial bolus of 0.25–1
g/kg (the higher dose for more urgent reduction of ICP) followed by 0.25–0.5 g/kg boluses
repeated every 2– 6 h as per requirement. Attention has to be paid to the fluid balance so as to
avoid hypovolemia and shock. There is also a concern of possible leakage of mannitol into
the damaged brain tissue potentially leading to “rebound” rises in ICP [13]. For this reason,
when it is time to stop mannitol, it should be tapered and its use should be limited to 48 to 72
h. Apart from hypotension, rebound rise in ICP, mannitol can also lead to hypokalemia,
hemolysis and renal failure.

Hypertonic Saline
Hypertonic saline has a clear advantage over mannitol in children who are hypovolemic or hypotensive. Other
situations where it may be preferred are renal failure or serum osmolality >320 mosmol/Kg. It has been found
effective in patients with serum osmolality of up to 360 mosmol/Kg [14]. Concerns with its use are bleeding,
rebound rise in ICP, hypokalemia, and hyperchloremic acidosis, central pontine myelinolysis, acute volume
overload, renal failure, cardiac failure or pulmonary edema [15–17]. Despite these concerns, current evidence
suggests that hypertonic saline as currently used is safe and does not result in major adverse effects [18]. In
different studies the concentration of hypertonic saline used has varied from 1.7% to 30% [18]. The method of
administration has also varied and hence, evidence based recommendations are difficult. It would be reasonable
to administer hypertonic saline as a continuous infusion at 0.1 to 1.0 mL/kg/hr, to target a serum sodium level of
145–155 meq/L [19, 20]. Serum sodium and neurological status needs to be closely monitored during therapy.
When the hypertonic saline therapy is no longer required, serum sodium should be slowly corrected to normal
values (hourly decline in serum sodium of not more than 0.5 meq/L) to avoid complications associated with
fluid shifts [6]. Monitoring of serum sodium and serum osmolality should be done every 2–4 h till target level is
reached and then followed up with 12 hourly estimations. Under careful monitoring, hypertonic saline has been
used for up to 7 days [21].

Other Agents
Acetazolamide (20–100 mg/kg/day, in 3 divided doses, max 2 g/day) is a carbonic anhydrase inhibitor that
reduces the production of CSF. It is particularly useful in patients with hydrocephalous, high altitude illness and
benign intracranial hypertension. Furosemide (1 mg/kg/day, q8hrly), a loop diuretic has sometimes been
administered either alone or in combination with mannitol, with variable success [22, 23]. Glycerol is another
alternative osmotic agent for treatment of raised ICP. It is used in the oral (1.5 g/kg/day, q4–6hrly) or
intravenous forms. Given intravenously, it reduces ICP with effect lasting for about 70 min without any
prolonged effect on serum osmolality [24]. Glycerol readily moves across the blood brain barrier into the brain.
Though not proven, thereis concern of rebound rise in ICP with its use.

Steroids
Glucocorticoids are very effective in ameliorating the vasogenic edema that accompanies tumors, inflammatory
conditions, infections and other disorders associated with increased permeability of blood brain barrier,
including surgical manipulation [25]. Dexamethasone is the preferred agent due to its very low
mineralocorticoid activity (Dose:0.4–1.5 mg/kg/day, q 6 hrly) [26]. Steroids are not routinely indicated in
individuals with traumatic brain injury [27]. Steroids have not been found to be useful and may be detrimental in
ischemic lesions, cerebral malaria and intracranial hemorrhage [26, 28, 29].

Sedation and Analgesia

Raised ICP is worsened due to agitation, pain, and patientventilator asynchrony [8]. Adequate analgesia,
sedation and occasionally neuromuscular blockade are useful adjuvant in the management of raised ICP.
Appropriate Analgesia and sedation is usually preferred over neuromuscular blockade, as it is quickly reversible
and allows for neurological monitoring. For sedation it is preferable to use agents with minimal effect on blood
pressure. Short acting benzodiazepines (e.g. midazolam) are useful for sedation in children. If the sedatives are
not completely effective, then a neuromuscular blocking agent (e.g. Pancuronium, atracurium,vecuronium) may
be required.