Evaluation and management of increased intracranial pressure.

PURPOSE OF REVIEW: : Persistent elevation of intracranial pressure (ICP) can lead to cerebral ischemia, brain herniation, and possibly death. Understanding the fundamental mechanism that contributes to the rise in ICP and recognizing the specific intracranial compartment involved (brain, CSF, or blood) can lead to early diagnosis and effective treatment. This article reviews the conceptual approach to a patient with elevated ICP.

RECENT FINDINGS: : The overall goal for patients with intracranial hypertension is to lower ICP below 20 mm Hg and to maintain cerebral perfusion pressure (CPP) between 60 mm Hg and 90 mm Hg to provide sufficient cerebral perfusion. Commonly used therapeutic interventions to lower ICP include decompressive surgery, osmotherapy, hyperventilation, barbiturate-induced metabolic suppression, and hypothermia; however, the selection of these interventions must be tailored to each patient by considering the particular diagnosis and intracranial pathophysiology. Emerging evidence suggests that cerebral autoregulation may fail at excessively high CPP (CPP greater than 100 mm Hg) as well as at low CPP (CPP less than 60 mm Hg) and that maximal cerebral autoregulation capacity may be achieved at an optimal CPP of 70 mm Hg to 90 mm Hg.

SUMMARY: : Increased ICP is a neurologic emergency that requires immediate intervention. However, the treatment itself is not without risk; thus, the risks and benefits of medical and surgical intervention must be carefully evaluated and individualized for each patient.