Bianchini L, Matos PMPG, Roepke RML, Besen BAMP. Management of intracranial hypertension with and without invasive intracranial pressure monitoring. World J Crit Care Med 2025; 14(3): 105645 [DOI: 10.5492/wjccm.v14.i3.105645]
Corresponding Author of This Article
Larissa Bianchini, MD, Medical Sciences Postgraduate Programme, Internal Medicine Department, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 225, Sao Paulo 05403-010, Brazil. larissa_bianchini@hotmail.com
Research Domain of This Article
Critical Care Medicine
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Crit Care Med. Sep 9, 2025; 14(3): 105645 Published online Sep 9, 2025. doi: 10.5492/wjccm.v14.i3.105645
Management of intracranial hypertension with and without invasive intracranial pressure monitoring
Larissa Bianchini, Paulo Marcelo Pontes Gomes de Matos, Roberta Muriel Longo Roepke, Bruno Adler Maccagnan Pinheiro Besen
Larissa Bianchini, Paulo Marcelo Pontes Gomes de Matos, Bruno Adler Maccagnan Pinheiro Besen, Medical Sciences Postgraduate Programme, Internal Medicine Department, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-010, Brazil
Larissa Bianchini, Paulo Marcelo Pontes Gomes de Matos, Bruno Adler Maccagnan Pinheiro Besen, Intensive Care Unit, Department of Medicine, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 05403-010, Brazil
Larissa Bianchini, Hcor Research Institute, HCOR, Sao Paulo 04004-030, Brazil
Roberta Muriel Longo Roepke, Trauma and Acute Care Surgery ICU, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
Bruno Adler Maccagnan Pinheiro Besen, IDOR Research and Education Institute, IDOR Research and Education Institute, Sao Paulo 01401-002, Brazil
Author contributions: Bianchini L conceptualization, literature search, and drafting of the original manuscript; Matos PMPG literature search, and drafting of the original manuscript; Roepke RML provided project oversight and contributed to the final revision; Besen BAMP contributed to the study design, supervised the project, and revised the manuscript critically. All authors reviewed and approved the final version of the manuscript.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Larissa Bianchini, MD, Medical Sciences Postgraduate Programme, Internal Medicine Department, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 225, Sao Paulo 05403-010, Brazil. larissa_bianchini@hotmail.com
Received: February 2, 2025 Revised: April 1, 2025 Accepted: April 15, 2025 Published online: September 9, 2025 Processing time: 167 Days and 19.4 Hours
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.
Core Tip: Intracranial hypertension (IH) is one of the most critical syndromes in critical care medicine. Its management is classically guided by invasive intracranial pressure (ICP) monitoring, although recent evidence has questioned the value of invasive ICP monitoring while advances in noninvasive assessment of cerebral dynamics have evolved. In this manuscript, we guide the readers through the recent evidence base, we critically discuss the literature and we provide suggested guidance to the management of IH with and without invasive ICP monitoring.
