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CDHB

Raised Intracranial Pressure

Clinical Features

These include a deteriorating level of consciousness, increasing drowsiness, stupor, coma/deteriorating GCS; lateralizing/focal neurological signs which may be progressive. Raised intracranial pressure can cause papilloedema in a proportion of patients - probably less than 50%, the remaining 50% or more will have raised intracranial pressure and will not develop papilloedema due to variations in the anatomy of the optic nerve sleeve.

Causes

Include intracranial mass lesion, obstruction to the flow of CSF (hydrocephalus), and brain swelling.

Investigations

• CT or MRI head scan is mandatory to establish the cause.
• Remember that many patients with raised intracranial pressure sufficient to cause death will not have or will never develop papilloedema.
• Do not dilate pupils.

Management

• Consult Neurosurgeon/Neurologist.
• Close observation with neurological recordings every 15-30 minutes will be needed in drowsy or deteriorating patients. This will require a special nurse. Do not, however, substitute observation for action since this may be needed urgently.
• Consider dexamethasone 4 mg IV/IM/PO q6h, especially if a tumour is present. Give dexamethasone 12 mg IV stat if the patient is drowsy. If the mental state declines further the patient may need mannitol 1 g/kg IV over 20-30 minutes (500 mL of 15% mannitol contains 75 g).
• Carefully assess adequacy of the airway. If necessary, intubation - to ensure a safe airway and adequate oxygenation.
• In an acute situation transfer to ICU while awaiting neurosurgical intervention.

Note: Lumbar puncture - never perform a lumbar puncture if a patient may have raised intracranial pressure without obtaining a CT/MRI scan first. Clues to the presence of raised intracranial pressure include the following - lateralizing (focal) features, focal seizures, drowsiness or papilloedema. When bacterial meningitis is strongly suspected, but features consistent with raised intracranial pressure are present, administer intravenous antibiotics immediately. Then arrange for urgent CT scan. If the CT shows no mass lesion nor any evidence of raised intracranial pressure, perform a lumbar puncture for CSF examination. Refer to Meningitis - Management and Lumbar Puncture.

Topic Code: 1527