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  • Intracranial hypertension is the final common pathway of morbidity and mortality for diverse neurologic problems, and its proper treatment requires the timely application of the available therapeutic alternatives when the clinical situation and prognosis warrant and justify treatment.
  • Anticipating patients at risk for brain swelling is important and allows the development of a strategic plan to limit its severity and facilitate early intervention when possible.
  • The initial therapeutic focus for intracranial pressure reduction should be the control of factors that can aggravate intracranial hypertension, such as inappropriate head and body position, elevated body temperature, inadequate treatment of pain and agitation, elevated airway pressures, blood pressure fluctuations, seizures, and administration of hypotonic fluids.
  • The appropriate conventional medical therapies should be selected based on the details of each specific case. It should be clear that brain tissue displacement (BTD) and intracranial hypertension are not synonymous, and the treatment of each of them can be different. Surgical removal of an intracranial mass lesion or expansion of the intracranial compartment should be considered in patients with severe BTD and/or evolving intracranial hypertension.
  • In the end, the treatment of intracranial hypertension is heuristic, challenging the managing physician's thorough understanding of the cause of the problem and his or her ability to define the human aspects that relate to determining the appropriate level of care for individual patients. In addition, successful management depends on a partnership with nurses founded on comprehensive communication to assist with the accurate translation of the defined care priorities.


Intracranial hypertension can be the result of a primary central nervous system process, or it can result as a complication of a concurrent systemic illness. Independent of the specific etiology, it is an important and potentially disabling and deadly complication. While it often has important prognostic implications, its successful management can protect the brain from secondary injury and improve outcome.The management of intracranial hypertension is frequently approached in an overly simplistic manner with the sequential application of various intracranial pressure (ICP)–lowering strategies in a cookbook fashion. However, such a simplistic approach to intracranial hypertension can be perilous and potentially aggravate the problem. The management of intracranial hypertension is best tailored to each specific situation. This chapter will introduce the basic principles that should be considered when arriving at an individualized strategic management plan for a patient with brain swelling and/or intracranial hypertension. While some of these concepts and treatment strategies are discussed in Chap. 93 in the context of head injury, we will present a more global view on the management of brain swelling and intracranial hypertension


Intracranial Pressure


When it is monitored, the ICP tracing is a ballistic waveform much like the systemic arterial pressure (Fig. 65-1). However, it has a narrow “pulse pressure” and is expressed, by convention, as its mean. The normal mean ICP is generally between 5 and 10 mm Hg, and it will fluctuate at times to higher levels depending on many physiologic ...

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