Management of intracranial hypertension with and without invasive intracranial pressure monitoring

Table 7 Tiers of therapy for intracranial hypertension

Tier 0: Basic neurocritical care management for ventilated patients at risk of intracranial hypertension

ICU admission with proper monitoring, including: (1) Invasive arterial pressure monitoring; (2) End-tidal CO2 monitoring; and (3) Core temperature measurement

Venous return optimization with: (1) Head-of-bed elevation to 30-45 ℃; (2) Midline head positioning; and (3) Avoidance of tight cervical collars when possible

Avoidance of ICP spikes with: (1) Analgesia and (2) Mild sedation (not ICP directed) to prevent pain, agitation and ventilator asynchrony

Avoidance of secondary insults, including:

(1) Hypoxemia: Target SpO2 94%-98%

(2) Hypotension: Avoid hypotension by targeting a minimal systolic arterial pressure of 100-110 mmHg or to CPP 60-70 mmHg

(3) Hypocapnia: Target PaCO2 to normal levels (35-40 mmHg)

(4) Hyponatremia: Target serum Na+ to 140-145 mmol/L

(5) Hyperthermia: Target core temperature to below 38 ℃

(6) Hypoglycemia: Target glucose levels to 110-180 mg/dL

Avoid anemia (i.e., Hb < 7.0 g/dL)

Consider anti-seizure prophylaxis for up to 1 week

Tier 1: Deep sedation, CPP optimization, EVD drainage and hyperosmolar therapy

Revise Tier 0 treatment:

(1) Target CPP of 60-70 mmHg or MAP 80-90 mmHg in absence of invasive ICP monitoring

(2) Maintain PaCO2 at lower end of normal (35-38 mmHg)

Intermittent bolus hyperosmolar treatment: (1) Hypertonic saline; and (2) Mannitol

Increase sedation beyond mild sedation to lower ICP (if measured) or to a target RASS of -4/-5 (if ICP not measured), but not to target burst-suppression

Cerebrospinal fluid drainage if external ventricular drain in situ or consider the placement of an EVD

Consider EEG monitoring (if available)

Tier 2: Additional measures with controversial effect

Mild hypocapnia in a lower range (32-35 mmHg)

Trial of neuromuscular paralysis (among ICP monitored patients)

If ICP decreases with a bolus, consider a continuous infusion

Trial of hemodynamic augmentation beyond usual CPP targets:

Perform MAP challenge to assess cerebral autoregulation: If ICP decreases with increased MAP, consider sustaining higher MAP, but no more than a CPP greater than 90 mmHg

Avoid any other adjustments during MAP challenges

In patients without ICP monitors, this trial may be considered with TCCD/TCD measurements

Tier 3: Highly efficacious therapies to reduce ICP, but with demonstrated increased risk of complications (i.e., should not be routinely used except under specific circumstances)

Barbiturate coma with pentobarbital or thiopentone to ICP control (if efficacious) or to pupil abnormality correction (when ICP is not measured)

Secondary decompressive craniectomy

Mild hypothermia (35-36 ℃) with active cooling measures

ICP: Intracranial pressure; MAP: Mean arterial pressure; CPP: Cerebral perfusion pressure; TCCD: Transcranial color-coded duplex scan; TCD: Transcranial doppler; EVD: External ventricular drain; ICU: Intensive care unit.