Raised Intracranial Pressure
Raised Intracranial Pressure
General and supportive measures
DESCRIPTION
Raised intracranial pressure (ICP) is an emergency requiring prompt recognition and treatment.
The cranial vault contains the brain, blood and CSF. It has a fixed volume, therefore, an increase in one component requires a compensatory decrease in others to maintain the pressure within the compartment. There is a limited capacity for compensation, i.e. by decreasing CSF volume, decreasing cerebral blood volume or by increasing the cranial volume. Thereafter, there is a rise in pressure.
Herniation syndromes are an important complication to consider. They may arise in the course of untreated underlying disease or as a result of injudicious lumbar puncture.
Normal CSF pressures range from:
- Infants: 20 – 27 cmH2O (1.5–6 mmHg).
- Children: 4 – 10 cmH2O (3–7 mmHg).
These values are for well children and may vary in those who are critically ill on ventilation.
Any CSF pressure above 27 cm of CSF (20 mmHg) for more than 20 minutes should be treated.
| Increased brain volume | Intracranial space occupying lesion: Brain tumour, brain abscess, haematoma, vascular malformation, arachnoid/ epidermoid cyst. |
| Cerebral oedema: encephalitis, meningitis, hypoxic ischaemic encephalopathy, traumatic brain injury, hepatic encephalopathy, Reye’s syndrome, stroke, diabetic ketoacidosis, hyponatraemia. | |
| Increased blood volume | Vascular malformations, cerebral venous thrombosis, meningitis, encephalitis. |
| Increased CSF volume | Obstructive/communicating hydrocephalus, choroid plexus papilloma. |
| Disordered CSF dynamics | Idiopathic intracranial hypertension. |
Source20
Vitamin A administration may cause benign raised ICP.
DIAGNOSTIC CRITERIA
Presentation may have an acute or insidious onset depending on the underlying pathology. A detailed history and examination are essential.
Clinical
Features vary with age.
Infants:
- Increasing head circumference.
- Sun setting eyes.
- Distended scalp veins.
- Irritability.
- Lethargy.
- Vomiting.
- Developmental delay or regression.
- Persistent head lag.
Older children:
- Headache.
- Vomiting.
- Depressed level of consciousness.
- Seizures.
- Ataxia.
- Abnormal eye movements.
- Double vision.
- Behavioural changes.
- Meningism.
Late signs:
- Papilloedema.
- Sixth nerve palsy.
- Pupillary dilation.
- Decerebrate or decorticate posturing.
- Cheyne-Stokes respiration.
- Focal neurological deficits.
- Cushing Triad:
- Increased systolic pressure (with widening pulse pressure).
- Irregular breathing.
- Bradycardia.
| Herniation syndromes | |
| Unilateral transtentorial herniation | Declining consciousness. Increased blood pressure. Slow pulse. Homonymous hemianopia. Respiratory irregularity. |
| Bilateral transtentorial herniation | Decerebrate or decorticate rigidity. Declining consciousness. Impaired upward gaze. Irregular respiration. Pupillary constriction or dilatation. |
| Cerebellar herniation | Declining consciousness. Impaired upward gaze. Irregular respiration. Lower cranial nerve palsies. Neck stiffness or head tilt. |
Source20
Investigations
- CT brain to determine underlying cause and whether it is safe to perform a lumbar puncture.
- CSF opening pressure (if no contraindication).
GENERAL AND SUPPORTIVE MEASURES
- Follow the ABCD algorithm.
- Position head in midline and elevate to 30∘.
- Cautious ventilation maintaining PaCO2 between 4.5 and 5 kPa.
- Monitoring and maintenance of blood pressure.
- Elevated BP is usually reactive and required to maintain cerebral perfusion.
- Monitor fluid balance, use 0.9% NaCl/5% dextrose water as maintenance fluid.
- Keep serum sodium in the upper range of normal, up to 150 mmol/L.
- Maintain normothermia.
- Maintain glucose within 6 to 10 mmol/L.
MEDICINE TREATMENT
Initiate treatment for underlying cause.
If meningitis cannot be excluded, commence treatment as soon as possible (see Meningitis, acute bacterial).
Sodium chloride, 5%, IV, 2 mL/kg infused over 30 minutes.
- Monitoring of serum sodium is essential with repeat doses or infusion.
OR
Mannitol, IV, 250 mg/kg administered over 30–60 minutes.
- Do not exceed two doses without consulting with a specialist.
If a space occupying lesion is diagnosed:
Add
- Dexamethasone, IV, 0.5 mg/kg 12 hourly.
- Maximum dose 12 mg per dose.
Sedation and analgesia, see Pain Control Chapter and Intensive Care Chapter.
Management of seizures if present, refer to: Seizures.
REFERRAL
- According to underlying condition.
- Neurosurgical intervention may be required.
Click here to access NEMLC Report.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Paediatric Hospital Level_Updated May 2025
Chapter 13: The Nervous System_13.12 Raised Intracranial Pressure