Skip to main content Accessibility help
  • Print publication year: 2003
  • Online publication date: August 2009

23 - Increased Intracranial Pressure and Herniation Syndromes



Primary survey of a patient suspected of having an increased intracranial pressure (ICP) consists of a brief neurological examination and establishment of a Glasgow Coma Scale (GCS) score. Brain herniation, an end-stage manifestation of increased ICP, refers to displacement of brain tissue from one intracranial compartment to another through an opening in the dural sheath. A herniation syndrome is a neurosurgical emergency; if immediate intervention is not taken, death can ensue rapidly. Initial therapy is aimed at lowering ICP while determining and treating the underlying cause. Common conditions resulting in increased ICP include traumatic brain injury (TBI), cerebrovascular events, hydrocephalus, brain tumor, central nervous system infections, metabolic and hypoxic encephalopathies, and status epilepticus. Mannitol, an osmotic diuretic, is currently the diuretic of choice for treating increased ICP. Barbiturate therapy is effective in lowering ICP in a select subset of patients such as those with persistently high ICP despite aggressive management.
Bingaman, W V, Frank, J I. Malignant cerebral edema and intracranial hypertension. Neurol Clin. 1995; 13: 479–509
Duncan C C, Ment L R. Central nervous system: head injury. In: Toulorian R J, ed. Pediatric Trauma, 2nd ed. Philadelphia, Pa: CV Mosby; 1990
Fink, M E. Emergency management of the head-injured patient. Emerg Med Clin North Am. 1987; 5: 783–95
Hareri, R J. Cerebral edema. Neurosurg Clin N Am. 1994; 5: 687–706
McGillicuddy, J E. Cerebral protection: pathophysiology and treatment of increased intracranial pressure. Chest. 1985; 87: 85–93
Pickard J D, Czosnyka M. Raised intracranial pressure. In: Hughes R A C, ed. Neurological Emergencies, 1st ed. London: BMG, 1994: 150–86
Wilkins R H, Rengochary S S, eds. Neurosurgery, 2nd ed. New York, NY: McGraw-Hill; 1996: 349
Wilkinson H A. Intracranial pressure. In: Youmans J R, ed. Neurosurgery. Philadelphia, Pa: WB Saunders: 1990: 661–91