Intracranial pressure, raised

Patients with acute stroke should be monitored intensely for the development of neurologic worsening, complications, and adverse effects from treatments. The most common reasons for clinical deterioration in stroke patients are (1) extension of the original lesion in the brain (2) development of cerebral edema and raised intracranial pressure (3) hypertensive emergency (4) infection (e.g., urinary and respiratory tract) (5) venous thromboembolism (6) electrolyte abnormalities and rhythm disturbances and (7) recurrent stroke. The approach to monitoring stroke patients is summarized in Table 13-3. 

Raised intracranial pressure could be a cause of early morning headache. Early morning headache could also be triggered by sinusitis, tension or muscle spasm. 

Betamethasone is hardly ever used orally. It has a long duration of activity and can therefore also be used for alternate-day therapy. The parenteral formulation is also the sodium phosphate salt which when given IV or IM has a rapid onset of action. There are many similarities with dexamethasone such as their metabolic pathways and the indications for which both steroids are used, like the prevention of neonatal RDS and reduction of raised intracranial pressure. Combinations of betamethasone acetate and sodium phosphate have, when used for intra-articular and intra-lesional injections, the dual advantage of a rapid onset of action together with the long duration of action of a depot preparation. 

Other reported side effects include vomiting, salivation, lacrimation, shivering, skin rash, and an interaction with thyroid preparations that may lead to hypertension and tachycardia. Ketamine also may raise intracranial pressure and elevate pulmonary vascular resistance, especially in children with trauma or congenital heart disease. Increases in intraocular pressure also may occur, and vigilance is required if ketamine is used in ocular surgery. 

A case of papilledema as a manifestation of raised intracranial pressure has been reported following withdrawal of topical glucocorticoids (SEDA-3, 305). 

The use of acetazolamide in the presence of unrecognized cerebral edema due to fat embolism, with sudden normalization of brain C02, as occurred in this patient when her previous state of hypocapnia was no longer sustained by ventilatory effort, resulted in cerebral acidosis, vasodilatation, and a further increase in intracranial pressure. This proved catastrophic and led to brainstem herniation and brain death. Acetazolamide should be avoided if at all possible in patients with bony and traumatic brain injuries, particularly during weaning from mechanical ventilation, since it can precipitate coning in patients with raised intracranial pressure. 

Lumbar puncture is considered mandatory in patients with suspected bacterial meningitis but the procedure can be hazardous with a risk of brain herniation in patients with raised intracranial pressure, and imaging with computed tomography or MRI is recommended for selected patients to detect brain shift. Patients who are in an immunocompromised state, have new-onset seizures, moderate-to-severe impairment of consciousness or signs that are suspicious of space-occupying lesions (e.g. papilloedema - oedema of the optic disk) should undergo neuroimaging prior to lumbar puncture. 

Codeine and morphine are contraindicated in acute respiratory depression, acute alcoholism and where there is a risk of paralytic ileus. They should also be avoided in patients with raised intracranial pressure or head injury and in comatose patients. 

Q10 An excessive amount of ADH may be produced by some brain tumours, certain drugs and some lung cancers. Since this causes a reduced water excretion, an excess of ADH leads to water retention and hyponatraemia. As hyponatraemia in the ECF causes passage of water into the body cells, there may be brain swelling, raised intracranial pressure and neurological symptoms, such as headache, muscle weakness, lethargy, nausea and vomiting, irritability, confusion and coma. 

Mackirdy C, Abass H. Lithium induced raised intracranial pressure. Aust NZ J Psychiatry 2002 36(3) 426. 

In the presence of acute neurological injuries, midazolam produces a high risk of raised intracranial pressure (34), and the risk of airway obstruction (35) is a further concern. 

If the perfusion pressure rises above the autoregulatory range, where compensatory vasoconstriction and cerebral perfusion pressure are maximal, then hyperemia occurs followed by vasogenic edema, raised intracranial pressure and the clinical syndrome of hypertensive encephalopathy. 

The hematoma continues to expand after stroke onset, frequently causing further deterioration (Brott et al. 1997 Leira et al. 2004). Some brainstem hemorrhages evolve subacutely, particularly those caused by a vascular malformation (O Laoire et al. 1982 Howard 1986). Any large hematoma may cause brain shift, transtentorial herniation, brainstem compression and raised intracranial pressure. Hematomas in the posterior fossa are particularly likely to cause obstructive hydrocephalus. Rupture into the ventricles or on to the surface of the brain is common, causing blood to appear in the subarachnoid space. 

Raised intracranial pressure ntracranial venous thrombosis (Ch. 29) nflammatory bowel disease (Ch. 6) Coeliac disease (Ch. 6)... 

Damaged brain appears to have impaired responsiveness to arterial partial pressure of carbon dioxide and oxygen as well as impaired autoregulation and perfusion reserve, increasing the likelihood of further secondary insults such as systemic hypoxia, hypotension and raised intracranial pressure (Cormio et al. 1997). There are good theoretical... 

Malignant middle cerebral artery territory infarction is defined as a large middle cerebral artery infarct with marked edema and swelling, leading to raised intracranial pressure and a high risk of coning (Fig. 

Patients who are taking a retinoid, especially in combination with a tetracycline, should be carefully counseled to seek evaluation in the event of the development of blurred vision (static or transient), double vision, and/or headaches.These patients should have been counseled to avoid vitamin A. Discontinuation of treatment usually permits resolution of the raised intracranial pressure and disc edema, but other interventions may be undertaken if warranted. 

Malfunctioning of the respiratory centre (raised intracranial pressure, severe pulmonary insufficiency) causes patients to be intolerant of opioids, and indeed any sedative may precipitate respiratory failure. 

Systemic or topical antimicrobial therapy (tetracycline, minocycline, erythromycin, at low dose) is used over months (response begins after 2 months). Bacterial resistance is not a problem benefit is due to suppression of bacterial lipolysis of sebum, which generates inflammatory fatty acids. Raised intracranial pressure with loss of vision has occurred with tetracycline used thus. 

Headache of raised intracranial pressure (cerebral oedema) responds to dexamethasone (10 mg i.v. 4 mg 6-hourly, 2-10 d) which reduces the pressure and to nonopioid anedgesics (see also Palliative care). 

Raised intracranial pressure (see p. 328) dexamethasone maybe used indefinitely reduce dose to 5 mg/d if practicable. 

Morphine is dangerous when the respiratory drive is impaired by disease, including CO2 retention from any cause, e.g. chronic obstructive lung disease, asthma or raised intracranial pressure. 

Contraindications include moderate to severe h)q ertension, congestive cardiac failure or a history of stroke acute or chronic alcohol intoxication, cerebral trauma, intracerebral mass or haemorrhage or other causes of raised intracranial pressure eye injury and increased intraocular pressvue psychiatric disorders such as a schizophrenia and acute psychoses. 

Raised intracranial pressure will be made worse by high expired concentration inhalation agents, e.g. > 1% isoflurane, by hypoxia or hypercapnia, and in response to intubation if anaesthesia is inadequate. Without support from a mechanical ventilator, excessive doses of opioids will cause hypercapnia and increase intracranial pressure. 

Adrenocortical steroids are used for their action on specific cancers and also to treat some of the complications of cancer, e.g. hypercalcaemia, raised intracranial pressure. Their principal use is in cancer of the lymphoid tissues and blood. In leukaemias they may also reduce the incidence of complications such as haemolytic anaemia and thrombocytopenia. A glucocorticoid is preferred, e.g. prednisolone, as high doses are used and mineralocorticoid actions are not needed and cause fluid retention. 

Central nervous system. Depression and psychosis can occur during the first few days of high dose administration, especially in those with a history of mental disorder. Other effects include euphoria, insomnia, and aggravation of schizophrenia and epilepsy. Long-term treatment may result in raised intracranial pressure with papilloedema, especially in children. 

Raised intracranial pressure may occur more readily in children than in adults. 

Raised intracranial pressure due to cerebral oedema, e.g. in cerebral tumour or encephalitis (probably an anti-inflammatory effect which reduces vascular permeability and acts in 12-24 h) give dexamethasone 10 mg i.m. or i.v. (or equivalent) initially and then 4 mg 6-hourly by the appropriate route, reducing dose after 2-4 days and withdrawing over 5-7 days but much higher doses may be used in palliation of inoperable cerebral tumour. 

Rare effects include raised intracranial pressure with papilledema (SEDA-12, 153) (112), retinal maculopathy (113), and retinopathy (97). 

Bilateral optic disc edema is sometimes associated with ciclosporin given for bone marrow transplantation, but unilateral papilledema with otherwise asymptomatic raised intracranial pressure can occur (42). Eight cases of optic disc edema have been reported in bone marrow transplant patients taking ciclosporin. In two of the patients there were other possible explanations, but in all cases withdrawal of ciclosporin resulted in resolution of the papilledema (43). 

Movement disorders after withdrawal of continuous infusion, without the characteristic autonomic signs of opioid withdrawal, have been reported in children (SEDA-17,80). Fentanyl-induced seizures have been reported (10). Life-threatening complications have included raised intracranial pressure and critically reducing cerebral perfusion (11). 

Halothane can cause an increase in intracranial pressure (15), as can other inhalational anesthetics, which can constitute a particular risk if the pressure is already raised before anesthesia. In neonates, the intracranial pressure may fall (16). 

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