Management of intracranial hypertension with and without invasive intracranial pressure monitoring

Table 1 Usual indications for intracranial pressure monitoring

Indication	Likelihood of ICH
Overt signs of intracranial hypertension	Very high
Herniation syndromes (specially anisocoria)
Cushing's triad
Comment (1): These cases are usually identified upon presentation and usually undergo surgical treatment followed by ICP monitoring, except for diffuse brain edema, where isolated ICP monitoring may be indicated; Comment (2): During the ICU stay, this may present as a neuroworsening scenario that prompts treatment escalation, sometimes regardless of ICP monitoring
High risk of intracranial hypertension with unreliable neurological examination	High (approximately 50%)
Coma (i.e., GCS ≤ 8) with abnormal head CT scans (cistern compression, midline shift, contusions, hematomas)
Comment (1): These cases usually don't have overt signs of intracranial hypertension. Coma may be a manifestation of intracranial hypertension or not, but monitoring is advised both to diagnose elevated ICP and eventually to guide treatment. Monitoring may be beneficial both to avoid overtreatment and undertreatment; Comment (2): In scenarios where ICP monitoring is unavailable, these patients represent the greatest challenge to address treatment escalation and de-escalation
Low risk of intracranial hypertension	Low (approximately 10%-15%)
Coma (i.e., GCS ≤ 8) with normal head CT scans
Comment: These cases are unlikely to benefit from ICP monitoring. Repeat CT scans, frequent neurological examinations and noninvasive strategies may help identify the few patients who develop intracranial hypertension

CT: Computed tomography; ICP: Invasive intracranial pressure; GCS: Glasgow Coma scale; ICH: Intracranial hemorrhage.