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; Neurophysiological monitoring; Transcranial doppler ultrasonography; Neuroimaging

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.