The Ten Controversial Questions in Managing Intracranial Hypertension

Dear Editor, Intracranial hypertension (ICH) is commonly seen in neurocritical care and may be a common presentation in neurological/neurosurgical pathways.[1] For effective management, it is necessary not only to avoid the risk factors but also to suspect the development of raised intracranial pressure (ICP) and early and effective intervention to reverse the process of secondary injury [Table 1]. Hypertonic saline has established itself in recent years as the preferred alternative to mannitol due to its ability to expand plasma volume, increase mean arterial pressure, and decrease ICP over the long term, and is considered the preferred option.[2] Decompressive craniectomy is a potent intervention for reducing ICP in refractory cases; however, its impact on long-term functional outcomes remains a matter of debate. The RESCUEicp trials[3] and DECRA[4] disagreed regarding the benefit of increased survival at the expense of significant disability, revealing results that, while demonstrating efficacy in controlling ICP, raised questions regarding subsequent quality of life.Table 1: The ten controversial Questions in managing intracranial hypertensionCurrent recommendations suggest intervening in the event of sustained ICPs above 22 mmHg. However, its widespread clinical implementation continues to be limited by the lack of standardization and the availability of resources in diverse healthcare settings.[5] Sedation decreases the cerebral metabolic rate and ICP, so it is essential in medical treatment. In a systematic review of randomized clinical trials, Roberts et al.[6] concluded that, although there is no conclusive superior agent, propofol given in prolonged infusion showed advantages in reducing ICP versus opioids such as morphine. Therapeutic hyperventilation reduces PaCO2, which induces cerebral vasoconstriction and, consequently, a decrease in ICP. The use of advanced monitoring techniques–such as brain oxygenation measurement and brain perfusion imaging–can facilitate a safer and more personalized application of this strategy.[7] The use of corticosteroids in the management of ICH, particularly in the setting of traumatic brain injury, has been widely discouraged following the results of the CRASH study,[7] which showed a significant increase in mortality associated with its administration. However, corticosteroids retain a therapeutic role in specific scenarios, such as vasogenic edema secondary to brain tumors or abscesses, where their effectiveness is well documented. External ventricular drainage (EVD) is an effective tool for reducing ICP, particularly in cases of acute hydrocephalus or intraventricular hemorrhage. However, controversy persists regarding the ideal time of insertion, the mode of drainage (intermittent vs. continuous), and its duration. A comparative study showed that continuous drainage allows for more effective control of ICP, although with a greater burden of infectious and mechanical complications.[8] Barbiturate-induced coma has been used as a second-line therapeutic measure in patients with refractory ICH, and the barbiturate coma was successful in controlling ICP in approximately 67% of patients with ICH, with a trend toward better survival in those with a favorable response to treatment.[9] EVDs enable therapeutic drainage and monitoring, but they also present a risk of infection. The best monitoring device is determined by the clinical situation, the patient’s anatomy, and the availability of resources. Conventionally, fixed thresholds (e.g., >20 or 22 mmHg) have been used to initiate interventions; personalized thresholds based on the pressure reactivity index may facilitate better outcomes.[10] In summary, as understanding of brain injuries increases, shifting from ICH treatment to personalized care becomes both inevitable and essential. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.