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Raised intracranial pressure (Intracranial Hypertension)

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The CT scan can be normal with intracranial hypertension, and so an LP is needed with measuring open pressures. LP only if no pressure gradient suspected in the ventricular system. So do not LP if a supratentorial mass or oedema or swelling or hydrocephalus.

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CSF production 500 ml/day

When not to LP after CT or MR imaging

Midline shift or herniation signs on CT or MRI
Large mass effect (e.g., tumour, haemorrhage, abscess) on CT or MRI
Ventricular obstruction causing hydrocephalus on CT or MRI

When to Get Imaging

Signs of raised ICP:
Severe headache
Altered level of consciousness
Papilledema (swelling of the optic disc)
Focal neurological signs (e.g., weakness, speech disturbances)
Seizures
Bradycardia and hypertension (Cushing's triad)

Aetiology

Hydrocephalus due to obstruction of ventricles (Non communicating)
Hydrocephalus due to reduced drainage (Communicating)
Head injury with oedema
Idiopathic Intracranial hypertension: no pressure gradient so LP is useful
Ischaemic stroke with Malignant MCA syndrome
Cerebral Venous sinus thrombosis
Colloid cyst blocks IIIrd ventricle
Acute Haemorrhage into brain
Subdural or Epidural haematomas
Primary Brain tumour with oedema
Metastatic Brain tumour with oedema
Brain Abscess and other infections

Common causes

Cause	Clinical Presentation	Diagnosis	Treatment
Traumatic Brain Injury (TBI)	Headache Nausea and vomiting Altered consciousness or coma Seizures Pupil asymmetry	CT Scan or MRI to assess for haemorrhage, fractures, or brain swelling Neurological exam	Head elevation Osmotic agents (e.g., mannitol, hypertonic saline) Decompressive craniectomy in severe cases Monitor intracranial pressure (ICP)
Brain Tumour	Progressive headache Visual disturbances Seizures Focal neurological deficits (e.g., weakness, speech issues)	MRI or CT scan to detect tumour location and size Biopsy for tumour classification	Surgical resection if feasible Radiation or chemotherapy for inoperable tumours Dexamethasone to reduce swelling
Hydrocephalus	Headache Gait disturbances Cognitive impairment Incontinence	CT or MRI to assess ventricular dilation Physical and neurological exams	Ventriculoperitoneal shunt Endoscopic third ventriculostomy (ETV) Monitor ICP
Intracerebral Haemorrhage (ICH)	Sudden severe headache Vomiting Loss of consciousness Neurological deficits (e.g., weakness, slurred speech)	CT scan to detect haemorrhage Coagulation profile to assess clotting function	Reverse anticoagulation if applicable Osmotic agents to reduce ICP Surgical evacuation of hematoma in severe cases
Infections (e.g., meningitis, encephalitis)	Fever Neck stiffness Altered mental status Seizures Photophobia	CSF analysis through lumbar puncture MRI or CT to detect brain swelling or abscess Blood cultures	Antibiotics or antiviral therapy based on infection Osmotic agents for ICP management Steroids to reduce inflammation
Idiopathic Intracranial Hypertension (IIH)	Headache (worse on waking) Visual disturbances (transient visual obscurations, diplopia) Papilledema Tinnitus	MRI or CT to exclude other causes Ophthalmological exam for papilledema CSF pressure measurement	Acetazolamide to reduce CSF production Weight loss and lifestyle changes Ventriculoperitoneal shunt in severe cases
Brain Abscess	Fever Headache Focal neurological deficits Seizures Nausea and vomiting	MRI or CT scan to detect abscess Blood cultures Needle aspiration for culture	IV antibiotics (e.g., ceftriaxone, metronidazole) Surgical drainage if necessary ICP monitoring
Malignant MCA Syndrome	Massive infarct in the middle cerebral artery territory Hemiparesis Hemianopia Altered consciousness due to cerebral edema	CT or MRI to detect large infarct and edema Monitor for signs of herniation	Decompressive craniectomy Osmotic agents (e.g., mannitol) Monitor ICP and manage symptoms
Cerebellar Stroke	Vertigo Ataxia Vomiting Dysarthria Rapid deterioration with risk of brainstem compression	CT or MRI to detect cerebellar infarction or haemorrhage Neurological examination for cerebellar signs	Surgical decompression if necessary Supportive care for brainstem compression Thrombolysis or thrombectomy for ischaemic stroke (if eligible)

Clinical

Headache when lying flat relieved by sitting/standing/coughing/straining
Spontaneous Vomiting which may occur without nausea suggest brainstem lesion affecting floor of IVth ventricle
Vomiting worsens headache which may worsen vomiting
Transient visual loss when when straining or bending
Papilloedema but a lack of does not mean ICP is normal
Upgaze and sunsetting eyes in infants
Diplopia due to a VIth nerve palsy as a false localising sign
Oculomotor palsy (IIIrd) due to uncus pressing on nerve
Coma is a sign of significant raised ICP due to dysfunction of Reticular activating system

Investigations

CT scan +/- Contrast
CT Chest/abdomen/Pelvis if metastases
MRI with Gadolinium as needed
MRV or CTV for CVT
LP for IIH assessment

Complications

Coma and death due to pressure on the brainstem
Hydrocephalus
Persisting Papilloedema can lead to optic nerve damage and blindness

Management

Hydrocephalus: Treat Cause, Insert shunt
Malignant MCA: Hemicraniectomy
Tumour Debulking/ Removal/Steroids/Radiotherapy
Idiopathic Intracranial hypertension: Diuretics/Shunting
Haematoma: Surgical removal

References

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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