Raised intracranial pressure and cerebral oedema — Rapid

Synopsis

Recognise intracranial hypertension before herniation, identify the mechanism and cause, stabilise cerebral perfusion, and use imaging, hyperosmolar rescue and definitive neurosurgical treatment safely.

Intracranial pressure rises when the fixed cranial volume can no longer compensate for expansion of brain tissue, blood or cerebrospinal fluid, eventually reducing cerebral perfusion and shifting tissue.
Causes include traumatic or spontaneous haemorrhage, tumour, infarction, infection, hydrocephalus, venous thrombosis, hepatic failure, hypoxic injury and idiopathic intracranial hypertension, each requiring different definitive treatment.
Progressive headache, vomiting, transient visual obscurations, diplopia from sixth-nerve palsy and papilloedema support a slower rise, but papilloedema can be absent in acute catastrophic pressure.

Key red flags

Impending herniation

A newly dilated pupil, extensor posturing, irregular respiration or hypertension with bradycardia requires immediate critical-care and neurosurgical action.

Investigation priorities

Emergency non-contrast CT brainFirst step

Detect haemorrhage, mass, hydrocephalus, infarct signs and major tissue shift quickly.

Management branches

Immediate rescueProtect cerebral oxygen delivery

Consciousness, pupils or posture deteriorates with suspected intracranial hypertension.

Activate critical-care and neurosurgical teams, secure airway and oxygenation as necessary, maintain blood pressure and place the head up with neck midline and venous drainage unobstructed.
Treat seizure, fever, agitation, hypoglycaemia and severe hypercapnia, using brief hyperventilation only as a monitored bridge when herniation is imminent.

Subacute papilloedemaProtect vision while establishing cause

A stable patient has headache, visual obscurations or optic-disc swelling without acute herniation signs.

Key medicines

Hypertonic sodium chlorideConcentration, bolus volume and repeat limits follow the local neurocritical-care protocol, central or peripheral access policy and measured sodium rather than a generic ward prescription.

MannitolUse a weight-based intravenous bolus from the current BNF and local intracranial-pressure protocol, with response and osmolar monitoring before any repeat dose.

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