Management of intracranial hypertension with and without invasive intracranial pressure monitoring

Abstract

Management of intracranial hypertension (IH) has improved in the last decades driven by advancements in monitoring technologies and a deeper understanding of its pathophysiology. Although intracranial pressure (ICP) catheters are still recommended by current guidelines for monitoring patients at risk of IH, these methods are not without limitations. Challenges include procedural complications, availability of these devices in many healthcare settings and technical issues. In this context, management in the absence of ICP monitoring is common and now it can be augmented by intensivist-led point-of-care ultrasound, which includes tools such as transcranial doppler, optic nerve sheath measurement and brain ultrasound. These methods offer anatomic information that can sometimes withhold repeated head computed tomography (CT) scans, but they are also a window into ICP dynamics without the associated risks of invasive monitoring and are reasonable alternatives for guiding treatment, provided an integration between neurological examination, head CT anatomical findings and noninvasive monitors is considered. This manuscript synthesizes the evidence for using invasive ICP monitoring and methods for non-invasive monitoring, more focused on the role of ultrasound, given its wider availability. We also propose a practical approach of how to integrate this information at bedside to avoid both under and overtreatment, by embracing a clinical epidemiology paradigm to guide management decisions.

Keywords: Intracranial hypertension; Intracranial pressure; Neuroimaging; Neurophysiological monitoring; Transcranial doppler ultrasonography.

Figure 1

Patients with clinical signs of intracranial hypertension must be submitted to a head computed tomography and ultrasound (neuro POCUS). An optic nerve sheath diameter larger than 6 mm and an elevated Pulsatility index at transcranial doppler are indicative of elevated pressure. “Tier zero” measures are initiated. In case of persistent intracranial hypertension, treatment must be escalated following the steps described in the text. CT: Computed tomography; IH: Intracranial hypertension; TCD: Transcranial doppler.