Raised intracranial pressure from brain metastases — Rapid

Synopsis

Recognise intracranial mass effect and impending herniation, stabilise airway and cerebral perfusion, define metastatic number and anatomy with appropriate imaging and coordinate corticosteroid, neurosurgical, radiosurgical and systemic treatment.

Brain metastases cause raised pressure through tumour volume, vasogenic oedema, haemorrhage and obstructive hydrocephalus; posterior-fossa lesions can deteriorate with little reserve.
Key features are progressive headache worse with cough or lying flat, vomiting, papilloedema, focal deficit, seizure, cognitive change and declining consciousness.
Immediate CT head is the first emergency study for herniation, haemorrhage or sudden deficit because it is fast; contrast-enhanced MRI is the reference standard for detecting and planning brain metastases when stable.
Give dexamethasone promptly for symptomatic tumour-related oedema or raised pressure, using the acute-oncology dose matched to severity and the shortest effective course with a documented taper.
Do not give prophylactic antiseizure medicine routinely to a patient with brain metastases who has never seized; treat a first seizure and review interactions with anticancer therapy.
A large accessible lesion causing mass effect, obstructive hydrocephalus or uncertain diagnosis may need urgent neurosurgical resection or CSF diversion.
Stereotactic radiosurgery is preferred local treatment for selected limited-volume disease; surgery, radiosurgery, whole-brain radiotherapy and systemic therapy are chosen from number, size, biology, prognosis and goals.
Monitor neurological examination, glucose, infection and steroid myopathy and re-image unexpected worsening to separate tumour progression, haemorrhage, treatment oedema and radionecrosis.

Key red flags

Reduced consciousness, pupillary asymmetry, abnormal posturing or a Cushing physiological pattern requires immediate herniation management.

A first seizure, status epilepticus or failure to recover promptly after a seizure in a cancer patient needs emergency assessment and imaging.

New focal weakness, aphasia, visual field loss, ataxia or rapidly worsening confusion may represent metastasis, haemorrhage or acute stroke.

Headache worse on waking, coughing, straining or lying flat with vomiting or papilloedema suggests raised intracranial pressure.

Anticoagulation and haemorrhage-prone melanoma, renal, thyroid or choriocarcinoma metastases increase concern for intratumoral bleeding.

Focal cortical syndrome

Weakness, aphasia, neglect, visual-field loss or focal seizure localises a lesion or haemorrhage and requires urgent imaging.

Posterior-fossa syndrome

Gait or limb ataxia, vertigo, dysarthria, cranial-nerve dysfunction and vomiting may precede abrupt hydrocephalus or brainstem compromise.

Herniation physiology

Declining consciousness, unequal or fixed pupils, abnormal posturing, irregular breathing, hypertension and bradycardia demands immediate neurocritical action.

Investigation priorities

First emergency non-contrast CT headFirst step

Detect haemorrhage, major mass effect, hydrocephalus and shift rapidly in an unstable or suddenly deteriorating patient.

Management branches

DeterioratingProtect brain and identify herniation

Consciousness, pupils, posture, breathing or focal neurology is worsening rapidly.

Use ABCDE with cervical-neutral head elevation, oxygen for hypoxaemia, glucose and blood gas, seizure control and avoidance of hypotension and hypercapnia.
Give dexamethasone promptly for suspected tumour-associated oedema, obtain immediate CT and contact neurosurgery, critical care and acute oncology together.
Treat obstructive hydrocephalus or a surgically accessible dominant mass urgently; use temporary hyperosmolar rescue only under neurocritical guidance while definitive decompression is mobilised.

Stable symptomaticDefine all intracranial disease

A cancer patient has new headache, focal symptom, seizure or cognitive change without herniation physiology.

Obtain contrast-enhanced MRI with a metastasis protocol and review anticoagulants, steroid exposure, previous brain treatment and current systemic cancer control.
Use dexamethasone for clinically important oedema, provide analgesia and antiemetic, and treat actual seizure with an interaction-conscious antiseizure medicine.
Present imaging, performance, histology and prognosis at the neuro-oncology MDT to select resection, stereotactic radiotherapy, whole-brain treatment or systemic therapy.

Key medicines

Dexamethasone for symptomatic cerebral oedemaUse 4 to 8 mg daily orally or intravenously in divided doses for mild to moderate symptoms and up to 16 mg daily for severe raised-pressure or focal symptoms under the acute neuro-oncology protocol, then taper as rapidly as clinically tolerated.Give promptly in a deteriorating known-cancer presentation, but obtain diagnostic tissue before prolonged steroid when lymphoma is possible and physiology allows. Monitor glucose, infection, delirium, sleep, gastric risk and proximal weakness.

Levetiracetam after seizureA common adult starting regimen after a brain-tumour seizure is levetiracetam 500 mg orally or intravenously twice daily, increased according to recurrence, renal function and specialist neurology advice.Do not prescribe prophylactically to every seizure-naive patient. Adjust for renal impairment and monitor somnolence, agitation, depression and suicidality; status epilepticus follows the emergency seizure protocol.

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