Increased intracranial pressure - NYSORA

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Increased intracranial pressure

Learning objectives

  • Describe the causes of and risk factors for increased intracranial pressure
  • Identify increased intracranial pressure
  • Manage increased intracranial pressure


  • Increased intracranial pressure (ICP) commonly occurs in patients with traumatic brain injury and subarachnoid hemorrhage 
  • It is the most frequent cause of morbidity and mortality in these patients
  • Brain tumors can also increase ICP
  • Increased ICP can impair cerebral perfusion pressure, cerebral blood flow, and cerebral oxygenation, resulting in ischemia, edema, and further increases in ICP
  • Can impede surgical access to deep lesions requiring brain retraction
  • Can predispose to or exacerbate brain retraction injury
  • Can complicate dural closure


  • Before craniotomy:
    • Hypertension
    • Bradycardia
    • Irregular respiratory pattern (Cushing reflex)
  • After craniotomy:
    • Tense dura
    • Brain swelling out of the dural opening
    • Difficult brain retraction
  • Quantitative measurements:
    • ICP monitoring (External ventricular drain, intraparenchymal pressure monitor)
    • ICP measurement (Pressure transducer slid into the epidural space from a burr hole or at the edge of a craniotomy)

Risk factors

  • Subdural ICP >10 mmHg
  • Peritumoral edema
  • Mean arterial blood pressure >140 mmHg
  • Intraoperative hypotension with systolic blood pressure <90 mmHg
  • Glioblastoma
  • Metastasis


  • Intracranial
    • Tumor
    • Infarct
    • Trauma
    • Hemorrhage
    • Hydrocephalus
    • abscess/infection
    • Parenchymal edema
    • Idiopathic
  • Extracranial
    • Airway obstruction
    • Hypoxia/hypercarbia
    • Hypertension exceeding cerebral autoregulatory capacity
    • Hypotension causing cerebral hypoperfusion and reflex vasodilation
    • Venous hypertension from outflow obstruction
    • Volatile anesthetics
    • Nitroglycerin
    • Sodium nitroprusside
    • Vomiting, coughing, pain, shivering, and seizure activity during awake craniotomy


intracranial pressure, icp, vasoconstriction, hyperventilation, inhalational anesthesia, hypertension, propofol, barbiturates, benzodiazepines, etomidate, opioids, nitrous oxide, therapeutic hypothermia, hypertonic saline, mannitol, acetazolamide, topiramate, tumor, hematoma, gyrus rectus, anterior temoral lobectomy, cerebellar tissue resection, dural expansion, decompressive craniectomy, hinge craniotomy, lumbar drain, external ventricular drain, fenestration of cisternal compartments, arachnoid dissection

Suggested reading

  • Desai VR, Sadrameli SS, Hoppe S, Lee JJ, Jenson A, Steele WJ, et al. Contemporary Management of Increased Intraoperative Intracranial Pressure: Evidence-Based Anesthetic and Surgical Review. World Neurosurgery. 2019;129:120-9.
  • Ragland J, Lee K. Critical Care Management and Monitoring of Intracranial Pressure. J Neurocrit Care. 2016;9(2):105-12.
  • Tameem A, Krovvidi H. Cerebral physiology. Continuing Education in Anaesthesia Critical Care & Pain. 2013;13(4):113-8.

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