Raised Intracranial Pressure (ICP)
Lesson Objectives
By the end of this lesson, learners should be able to:
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Define intracranial pressure (ICP) and recognize normal vs. raised values.
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Identify the causes of raised ICP in children.
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Recognize age-specific clinical signs and symptoms.
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Outline investigations needed to diagnose the cause and assess severity.
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Describe supportive and pharmacological management.
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Monitor for complications and adjust therapy accordingly.
Description
Intracranial pressure (ICP) is the pressure within the cranium, normally 5–15 mmHg. Raised ICP is considered when pressure exceeds 20 mmHg for a sustained period.
Common causes include traumatic brain injury with mass effect, large vessel ischemic stroke, cerebral oedema, intracranial haemorrhage, hydrocephalus, diffuse cerebral oedema (e.g., hepatic failure, encephalitis, meningitis), jugular venous obstruction, brain neoplasms, and idiopathic oedema.
Clinical Features
| Age Group | Signs and Symptoms |
|---|---|
| Infants | Increasing head circumference, sun-setting eyes, distended scalp veins, irritability, lethargy, vomiting, developmental delay/regression, apnoea and bradycardia in neonates |
| Older Children | Headache, vomiting, depressed level of consciousness, seizures, ataxia, abnormal eye movements, double vision, behavioural changes, meningism |
| Late/Severe Signs | Anisocoria, sixth nerve palsy, pupillary dilation, decerebrate/decorticate posturing, Cheyne-Stokes respiration, focal neurological deficits, Cushing triad (increased systolic BP with widened pulse pressure, bradycardia, irregular respiration) |
Investigations
| Investigation | Purpose |
|---|---|
| CT Brain | Determine underlying cause, assess cerebral oedema, and evaluate safety for lumbar puncture |
| Other tests | As indicated for underlying cause (infection, trauma, coagulopathy) |
Supportive Management
| Step | Action |
|---|---|
| ABCDE | Stabilize airway, breathing, circulation, disability, and evaluation |
| ICU Admission | PICU if available |
| Positioning | Head midline, elevated at 30 degrees |
| Monitoring | BP (50th–95th percentile, permissible +20%), pulse, respiratory rate, GCS, blood glucose (6–10 mmol/L), temperature, signs of ICP |
| Other Support | Treat CNS infection if suspected, seizures, pain control |
| Fluids | Dextrose Normal Saline (DNS) as maintenance |
Pharmacological Management
| Drug / Therapy | Dosage / Administration | Notes |
|---|---|---|
| Hypertonic saline (3%) | 10 mL/kg IV over 30 mins (max 250 mL) | Monitor serum sodium, fluid output |
| Mannitol | 0.25–1 g/kg IV over 30 mins (commonly 250 mg/kg) | Strict monitoring of urine output |
| Dexamethasone | 0.15 mg/kg IV every 6 hours (max 12 mg/dose) | Indicated if ICP due to space-occupying lesion |
Summary
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ICP > 20 mmHg is considered raised.
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Causes include trauma, stroke, cerebral oedema, haemorrhage, hydrocephalus, neoplasms, and idiopathic oedema.
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Age-specific features must be recognized early: infants often present with increasing head circumference, older children with headache, vomiting, and neurological deficits.
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CT brain is essential for identifying the cause and guiding management.
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Supportive care: ABCDE stabilization, PICU admission, head positioning, monitoring, and maintenance fluids.
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Pharmacological care: hypertonic saline, mannitol, and dexamethasone as indicated.