Management Raised Intra-Cranial Pressure in Children

Introduction to Raised Intra-Cranial Pressure in Children

Raised intracranial pressure (ICP) in children is a serious medical condition characterized by increased pressure within the cranial vault. It can result from various underlying causes and requires prompt recognition and management to prevent severe neurological sequelae.

Key points:

Normal ICP: 5-15 mmHg in children; <5 mmHg in infants
Raised ICP is defined as sustained ICP >20 mmHg
Can lead to decreased cerebral perfusion and brain herniation if left untreated
Management requires a multidisciplinary approach in a pediatric intensive care setting

Etiology of Raised Intra-Cranial Pressure in Children

Raised ICP in children can result from various causes, often categorized based on the Monro-Kellie doctrine:

Increased brain tissue volume:
- Traumatic brain injury
- Brain tumors
- Cerebral edema (various causes)
- Infections (meningitis, encephalitis)
Increased cerebrospinal fluid (CSF) volume:
- Hydrocephalus
- Choroid plexus tumors
- CSF outflow obstruction
Increased blood volume:
- Arteriovenous malformations
- Venous sinus thrombosis
- Hypertensive encephalopathy
Others:
- Metabolic disorders (e.g., diabetic ketoacidosis)
- Toxins (e.g., lead encephalopathy)
- Idiopathic intracranial hypertension

Clinical Presentation of Raised Intra-Cranial Pressure in Children

The clinical presentation can vary depending on the child's age, the underlying cause, and the rate of ICP increase. Common signs and symptoms include:

Headache (often worse when lying down or in the morning)
Vomiting (especially projectile)
Altered mental status or irritability
Visual disturbances (blurred vision, diplopia)
Papilledema
Cranial nerve palsies (especially CN VI)
Cushing's triad (in severe cases):
- Hypertension
- Bradycardia
- Irregular breathing

In infants, additional signs may include:

Bulging fontanelle
Separated sutures
Increased head circumference
Setting-sun sign (downward gaze)

Diagnosis of Raised Intra-Cranial Pressure in Children

Diagnosis involves a combination of clinical assessment, neuroimaging, and in some cases, direct ICP measurement:

1. Clinical Assessment:

Thorough neurological examination
Fundoscopic examination for papilledema
Head circumference measurement in infants

2. Neuroimaging:

CT scan: Rapid assessment for space-occupying lesions, hydrocephalus, or midline shift
MRI: Detailed evaluation of brain parenchyma and potential causes
Transcranial Doppler: Non-invasive assessment of cerebral blood flow

3. ICP Monitoring:

Invasive ICP monitoring devices:
- Intraventricular catheter (gold standard)
- Intraparenchymal monitors
- Subdural or epidural monitors

4. Additional Tests:

Lumbar puncture: Contraindicated if there's risk of herniation
Electroencephalography (EEG): To assess for seizure activity
Laboratory tests: To identify underlying metabolic or infectious causes

Management of Raised Intra-Cranial Pressure in Children

Management of raised ICP in children requires a tiered approach, often in a pediatric intensive care setting:

1. General Measures:

Head elevation to 30 degrees
Neutral neck position
Avoid tight cervical collars
Maintain normothermia
Ensure adequate oxygenation and ventilation
Control pain and agitation

2. First-Tier Interventions:

CSF drainage if intraventricular catheter is in place
Hyperosmolar therapy:
- Mannitol (0.25-1 g/kg IV)
- Hypertonic saline (3% NaCl, 2-5 mL/kg)
Mild hyperventilation (PaCO2 30-35 mmHg)

3. Second-Tier Interventions:

Barbiturate coma (e.g., pentobarbital)
Decompressive craniectomy
Therapeutic hypothermia (controversial in children)

4. Specific Treatments:

Treat underlying causes (e.g., evacuation of hematoma, tumor resection)
Antibiotics for infectious causes
Antiepileptic drugs if seizures are present

5. Monitoring and Goals:

Maintain ICP <20 mmHg
Ensure cerebral perfusion pressure (CPP) >40-50 mmHg
Continuous EEG monitoring in comatose patients
Serial neurological examinations

Complications of Raised Intra-Cranial Pressure in Children

Untreated or severe raised ICP can lead to several complications:

Brain herniation (various types, including uncal and tonsillar)
Ischemic brain injury
Seizures
Visual impairment or blindness
Cognitive impairment
Endocrine dysfunction (if hypothalamic-pituitary axis is affected)
Death

Treatment-related complications may include:

Infection or bleeding from invasive monitoring
Rebound intracranial hypertension after osmotherapy
Electrolyte imbalances
Acute kidney injury

Prognosis of Raised Intra-Cranial Pressure in Children

The prognosis for children with raised ICP varies significantly depending on the underlying cause, severity, duration of increased ICP, and promptness of treatment:

Mortality rates can range from 20-50% in severe cases
Long-term neurological sequelae are common in survivors

Factors associated with better outcomes:

Early recognition and treatment
Reversible underlying causes
Absence of significant secondary brain injury
Younger age (due to greater neuroplasticity)

Factors associated with poor prognosis:

Prolonged duration of raised ICP
Presence of brain herniation
Multiple organ dysfunction
Refractory intracranial hypertension

Long-term follow-up and rehabilitation are essential for all children who survive episodes of significant raised ICP to optimize functional outcomes and quality of life.