DOI 10.1007/s12098-010-0190-2
Received: 3 August 2010 / Accepted: 18 August 2010 / Published online: 7 September 2010
# Dr. K C Chaudhuri Foundation 2010
Introduction
Raised intracranial pressure (ICP) is a common neurological complication in critically ill children. The cause may be
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Clinical manifestations
ABCs
The assessment and management of the airway, breathing
and circulation (ABCs) is the beginning point of management. Early endotracheal intubation should be considered
Positioning
Mild head elevation of 1530 has been shown to reduce
ICP with no significant detrimental effects on CPP or
CBF [7]. The childs head is positioned midline with the
head end of the bed elevated to 1530 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 3035 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].
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Immediate Measures*
.
.
Ongoing care
Sedation and analgesia
Avoid noxious stimuli
Control fever
Prevention and treatment of
seizures
Surgical intervention
Evacuation of hematoma
Maintain euglycemia
Neuroimaging : Suggestive of
surgically remediable cause;
hydrocephalous, large hematoma, etc
Yes
CSF diversion
Decompressive craniectomy
No or delay
Osmotherapy**
BP Normal: Mannitol
Other options;***
.
.
.
Special situations
.
.
Steroids: Intracranial tumors with perilesional edema, neurocysticercosis with high lesion load,
ADEM, pyomeningitis,TBM, Abscess
Acetazolamide: Hydrocephalus, Benign intracranial, high altitude illness
(*- May be initiated immediately after brief evaluation if situation is urgent. Measures also used in children awaiting surgical/radiologial
procedures, ** -Preferable to monitor ICP, ***- undertake only with ICP monitoring)
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
0.251 g/kg (the higher dose for more urgent reduction of
ICP) followed by 0.250.5 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
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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:
0.41.5 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].
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Minimization of Stimulation
Fluids
Anemia
Blood Glucose
Blood glucose must be maintained between 80120 mg/dL in
a child with raised ICP [7]. Studies in children with traumatic
brain injury have shown that hyperglycemia is associated
with poor neurological outcome and increased mortality [31].
On the other hand, hypoglycemia is known to induce a
systemic stress response and cause disturbances in CBF,
increasing the regional CBF by as much as 300% in severe
hypoglycaemia. Hypoglycemia can also lead to neuronal
injury and therefore, should be managed aggressively.
Temperature Regulation
Maintaining normothermia is important to prevent complications of temperature fluctuations. This is achieved by
frequent measurements of body temperature and correcting
any fluctuations using antipyretics, and assisted cooling or
heating per needed.
Surgical Therapy
Cerebrospinal Fluid Drainage CSF drainage using a
external ventricular drainage (EVD) or ventriculoperitoneal
shunt provides for an immediately effective means to lower
ICP. In addition EVD provides a method for continuously
monitoring ICP. CSF drainage is particularly useful in the
presence of hydrocephalus. But it may be considered even
in children without hydrocephalus. Its effectiveness in
lowering ICP has been shown to be comparable to
intravenous mannitol or hyperventilation [33]. However, it
is of limited utility in diffuse brain edema with collapsed
ventricles.
Resection of Mass Lesions Surgery should be undertaken
when a lesion amenable to surgical intervention is identified
as the primary cause of raised ICP. Common situations
where this neurosurgical intervention is preferentially
employed are acute epidural or subdural hematomas, brain
abscess, or brain tumors.
Target of Therapy
When facilities for ICP monitoring are available, the
management is tailored to maintaining an adequate CPP
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Hypothermia
Evidence from carefully conducted studies in adults and
children does not show any improvement in the neurologic
outcome in head injured patients with the use of therapeutic
hypothermia [35, 36]. However, studies do suggest a
lowered ICP during the hypothermia therapy in children
[35, 37]. So, in children with refractory raised ICP,
controlled hypothermia may be considered.
Decompressive Craniectomy On rare occasions when all
other measures fail, decompressive craniectomy with
duraplasty may be valuable procedure. Reports of its use
in children with traumatic brain injury have shown benefit
[38, 39]. It may offer an alternative treatment option in
uncontrolled ICP refractory to other measures.
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References
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1. Welch K. The intracranial pressure in infants. J Neurosurg.
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2. Castillo LR, Gopinath S, Robertson CS. Management of intracranial hypertension. Neurol Clin. 2008;26:52141.
3. Mazzola CA, Adelson PD. Critical care management of head
trauma in children. Crit Care Med. 2002;30:S393401.
4. Adelson PD, Bratton SL, Carney NA, et al. Guidelines for the
acute medical management of severe traumatic brain injury in
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