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Cerebral Edema and Elevated Intracranial Pressure
- Common in both ischemic and hemorrhagic strokes
- Concerning as it can lead to hydrocephalus (such as in cerebellar stroke obstruction the fourth ventricle) and/or create pressure differences between dura à Increase ICP à HERNIATION and DEATH
Elevated Intracranial Pressure
- Defined as ICP > 20 mmHg
- Cerebral Perfusion Pressure (CPP) = MAP – ICP
- CPP to maintain cerebral blood flow = 60 – 70 mmHg
- Can decrease with hypotension (drop in MAP) or elevated ICP
- Goal to maintain MAP between 60-70 mmHg
- Indications for ICP and CPP Monitoring in TBI with intraventricular catheter, intraparenchymal transducer (no guidleines or recommendations in other conditions)
- GCS < 8 + hematoma/herniation/cerebral edema etc. noted on CT
- Normal CT scan + at least 2 of following
- Age > 40
- Unilateral or bilateral motor posturing
- SBP < 90
Management of Elevated ICP
- Elevate the head of the bed > 30°
- Sedate the patient – propofol
- If patient has brain tumor w. surrounding edema (vasogenic edema) -> DEXAMETHASONE
- Create Hyperosmolar serum à Hypertonic saline or mannitol
- Hypertonic saline 3%, 7.5%, 23.4% (> 3% need central line)
- Must bolus! Continuous gtt only has transient benefit
- Harmful if Na > 160 and osmols > 320.
- Measure serum Osm + BMP 20 minutes after bolus then q 6 hours-> goal serum Na 145-155 and Osm 300-320
- ICP continues to be >20
- CT head -> look for new bleed, evidence of hydrocephalus
- CSF drain via ventriculostomy or decompressive craniotomy -> controversial for TBI and ICH, improves morbidity and mortality in malignant MCA strokes
Consider tertiary measures including sedation to burst suppression or hypothermia