FFinalistSouthampton · 2027
Acute care
AKT · Acute care/Neurological

Raised intracranial pressure

Raised ICP → reduced cerebral perfusion ± herniation

Overview

A rise in intracranial pressure (mass, bleed, oedema, hydrocephalus) that threatens cerebral perfusion and risks herniation ("coning"). Recognised by the clinical triad and pupil/conscious-level change; managed by treating the cause and temporising measures.

Recognise

  • Headache (worse lying/morning), vomiting, papilloedema, reduced GCS
  • Cushing reflex (LATE): hypertension + bradycardia + irregular breathing
  • Pupil changes: a fixed, dilated pupil = uncal herniation compressing CN III — emergency

Red flags

  • Falling GCS, a new fixed dilated pupil, Cushing reflex → impending herniation; neurosurgical emergency

Differentials & how to tell them apart

Migraineno focal deficit/papilloedema/reduced GCS; recurrent stereotyped
Idiopathic intracranial hypertensionraised ICP signs but normal imaging, typically young obese woman
Meningitisfever, meningism; LP only once mass/raised ICP excluded
Hypertensive encephalopathyvery high BP, normalises with BP control

Investigations

Urgent CT head; do NOT do an LP if raised ICP/mass suspected (risk of coning); bloods/clotting.

Management

Treat the cause; temporise: head-up 30°, normocapnia, osmotic therapy; urgent neurosurgery

  1. 1ABC; nurse head-up 30°, maintain oxygenation and normocapnia, avoid hypotension; urgent CT and neurosurgical referral.Gate: Do NOT perform a lumbar puncture when raised ICP / a mass lesion is suspected — it can precipitate fatal coning
  2. 2Osmotic therapy (mannitol/hypertonic saline) to temporise; dexamethasone only for tumour-associated oedema; definitive treatment of the cause (evacuate haematoma, CSF diversion).
Mannitol or hypertonic saline — osmotic reduction of ICP (temporising, specialist)
Dexamethasone — for vasogenic oedema around a tumour (NOT trauma/stroke)

Key points

A unilateral fixed dilated pupil = third-nerve compression from herniation — call neurosurgery now. The Cushing reflex is a late, pre-terminal sign.

Monitor & prognosis

GCS, pupils, BP/HR, repeat imaging; ICP monitoring in ICU.

Depends on cause and speed of decompression.

Source: NICE NG232 (head injury); neurosurgical guidance