Perfusion deficits; core vs. penumbra; vasospasm patterns
Contrast requirements
Fundoscopic examination
STAT
STAT
ROUTINE
STAT
Papilledema detection (takes hours-days to develop); retinal hemorrhages (Terson syndrome in SAH); IIH evaluation
Papilledema (indicates chronically or subacutely elevated ICP); absent papilledema does NOT exclude acute ICP elevation; venous pulsations absent if ICP >180 mm H2O
None
Formal visual field testing
-
-
ROUTINE
-
IIH monitoring; chronic elevated ICP; document visual field loss for treatment decisions
Enlarged blind spot; peripheral constriction; nasal field loss
Gold standard for ICP measurement; indications: GCS ≤8 with abnormal CT, or GCS ≤8 with normal CT + 2 of (age >40, SBP <90, motor posturing); also for hydrocephalus management; typically EVD or parenchymal monitor
Direct ICP measurement; normal <15 mmHg; elevated >20-22 mmHg; treatment threshold >22 mmHg (Brain Trauma Foundation 2016)
Coagulopathy (correct first); infection at insertion site; uncontrolled bleeding diathesis
IIH diagnosis and treatment: measure opening pressure → therapeutic CSF removal; CONTRAINDICATED if mass lesion, obstructive hydrocephalus, or herniation risk; imaging FIRST
Opening pressure: normal <20 cm H2O (obese <25); IIH: >25 cm H2O with normal CSF composition; high-volume tap (20-30 mL) for symptomatic relief in IIH
ABSOLUTE CONTRAINDICATION: Mass lesion with mass effect; obstructive hydrocephalus; impending herniation; posterior fossa mass; midline shift; anticoagulation/coagulopathy; skin infection at LP site
0.3 mg/kg :: IV :: - :: GCS ≤8: Secure airway; RSI with agents that do NOT raise ICP; preferred: etomidate 0.3 mg/kg OR propofol 1-2 mg/kg + rocuronium 1.2 mg/kg OR succinylcholine 1.5 mg/kg; AVOID ketamine in severe TBI (controversial — emerging data suggest may be safe); lidocaine 1.5 mg/kg IV 2-3 min before laryngoscopy (may blunt ICP spike — controversial benefit); avoid hypotension during RSI
-
Airway protection; ventilation control (PaCO2 management); GCS ≤8 cannot protect airway; avoid hypoxia (PaO2 <60) and hypotension (SBP <90) — both worsen outcomes
STAT
STAT
-
STAT
Head of bed elevation
-
-
N/A :: - :: continuous :: Elevate HOB 30°; neutral head position (avoid neck flexion/rotation that impedes jugular venous drainage); avoid tight cervical collar if possible; reverse Trendelenburg if cervical spine immobilization required
-
Promotes venous drainage; reduces ICP by 3-5 mmHg; no evidence of reduced CPP with 30° elevation; simple and immediate intervention
BTF Guidelines: Avoid prophylactic hyperventilation; use only for acute ICP crisis/herniation as bridge to definitive therapy; prolonged hyperventilation causes rebound vasodilation and ischemia; monitor with SjvO2 or PbtO2 if prolonged use needed
STAT
STAT
-
STAT
Osmotherapy — Mannitol
IV
-
1-1.5 g/kg :: IV :: PRN :: Mannitol 20%: 1-1.5 g/kg IV bolus (e.g., 100g = 500 mL of 20% for 70 kg patient) over 15-20 minutes; repeat doses: 0.25-0.5 g/kg q4-6h PRN; Hold if: serum osmolality >320 mOsm/kg, osmolar gap >15-20; Requires: Foley catheter (massive diuresis); volume replacement; Onset: 15-30 min; Duration: 2-6 hours
-
Creates osmotic gradient → draws water from brain parenchyma; reduces brain volume; also improves blood rheology; BTF: Level II evidence; monitor for renal toxicity (ATN), hypovolemia, rebound edema
STAT
STAT
-
STAT
Osmotherapy — Hypertonic Saline
IV
-
30 mL :: IV :: Continuous :: 23.4% NaCl: 30 mL IV bolus over 15-20 min via central line (preferred for acute crisis); 3% NaCl: 250-500 mL IV bolus over 30 min (can give peripherally); Continuous infusion: 3% NaCl at 30-50 mL/hr to maintain Na 145-155 mEq/L; Target sodium: 145-155 mEq/L; avoid >160; correct slowly if hypernatremia develops (no faster than 8-10 mEq/24h decrease)
-
Equivalent or superior to mannitol for ICP reduction; does NOT cause diuresis (better for hypovolemic patients); no osmolality ceiling (unlike mannitol); does not accumulate in injured brain (mannitol may); preferred in many centers; SAFE-TBI trial (2021): 20% mannitol = HTS for ICP control
STAT
STAT
-
STAT
Sedation and analgesia
-
-
25-75 mcg/kg :: - :: - :: Goal: Reduce metabolic demand, prevent agitation-induced ICP spikes; Propofol: 25-75 mcg/kg/min (first-line; reduces CMRO2 and ICP; allows rapid awakening for neuro exams); Fentanyl: 25-100 mcg/hr (analgesia without histamine release); Midazolam: 0.05-0.2 mg/kg/hr (alternative to propofol); Avoid: Ketamine in severe ICP (controversial); prolonged propofol (PRIS syndrome >48-72h at high doses)
-
Agitation, pain, coughing raise ICP; sedation reduces cerebral metabolic rate; propofol has favorable ICP properties; daily sedation holiday for neuro assessment if stable
STAT
STAT
-
STAT
Neuromuscular blockade
IV
-
0.1-0.2 mg/kg :: IV :: once :: For refractory ICP spikes with ventilator dyssynchrony, coughing, posturing; Cisatracurium 0.1-0.2 mg/kg bolus → 1-3 mcg/kg/min infusion (organ-independent metabolism); Rocuronium 0.6-1 mg/kg bolus → 0.6 mg/kg/hr; Requires: Concurrent sedation/analgesia; train-of-four monitoring; prevents detection of seizures (need cEEG)
-
Prevents ICP spikes from coughing, posturing; reduces intrathoracic pressure; use judiciously — obscures neuro exam and seizure detection; requires cEEG monitoring
-
STAT
-
STAT
Seizure prophylaxis / treatment
IV
-
1000-1500 mg :: IV :: q12h :: Prophylaxis (TBI): Levetiracetam 1000-1500 mg IV load → 500-1000 mg q12h x 7 days (BTF: early seizure prophylaxis x 7 days for severe TBI); Active seizure: Lorazepam 0.1 mg/kg (max 4 mg) → Levetiracetam 60 mg/kg load (max 4500 mg) OR fosphenytoin 20 mg PE/kg; Status epilepticus: Per SE protocol
-
Seizures dramatically increase CMRO2 and ICP; early seizures occur in 10-15% of severe TBI; prophylaxis beyond 7 days NOT recommended (does not prevent late epilepsy); levetiracetam preferred (no drug interactions, IV/PO equivalent)
STAT
STAT
-
STAT
Temperature control
-
-
650-1000 mg :: - :: - :: Avoid fever aggressively: fever increases CMRO2 by 10-13% per °C; target 36-37°C; acetaminophen 650-1000 mg q4-6h; cooling blankets; Therapeutic hypothermia: 32-35°C controversial; EUROTHERM (2015) showed harm from prophylactic hypothermia to 32-35°C in TBI; may use for refractory ICP as rescue
-
Fever worsens neurologic outcomes; aggressive normothermia is standard; therapeutic hypothermia is rescue therapy only (not prophylactic); if used: 32-35°C, avoid shivering (increases CMRO2), slow rewarming
STAT
STAT
-
STAT
Blood pressure / CPP management
IV
-
N/A :: IV :: continuous :: Target CPP 60-70 mmHg (CPP = MAP - ICP); avoid CPP <60 (ischemia) and >70 (BTF: avoid aggressive CPP >70 due to ARDS risk); If hypotensive: IV fluids (isotonic crystalloid; avoid hypotonic fluids); vasopressors (norepinephrine first-line); If hypertensive with ICP crisis: Treat ICP first (osmotherapy, sedation); avoid precipitously lowering BP (reduces CPP)
-
CPP is the primary determinant of cerebral perfusion; BTF 2016: target CPP 60-70; lower threshold 60 mmHg; aggressive CPP >70 increases ARDS risk without outcome benefit; individualized based on autoregulation status
N/A :: - :: once :: Indications (BTF 2016): GCS ≤8 + abnormal CT; OR GCS ≤8 + normal CT + ≥2 of: age >40, SBP <90, motor posturing; EVD preferred if: Hydrocephalus; need for CSF drainage; Parenchymal monitor if: No hydrocephalus; cannot drain CSF; Target ICP: <22 mmHg (BTF 2016); some centers use <20
-
Invasive ICP monitoring guides therapy; EVD allows therapeutic CSF drainage; parenchymal monitors cannot drain; infection risk ~5-10%; ventriculostomy is both diagnostic and therapeutic
-
STAT
-
STAT
CSF drainage (via EVD)
-
-
5-10 mL :: - :: Continuous :: Continuous drainage: Set drain to maintain ICP <22 mmHg; drain 5-10 mL CSF if ICP spike; Intermittent drainage: Drain for ICP >22, then clamp to re-measure; Typical: Remove 5-20 mL for ICP crisis; Rate: Avoid draining >20 mL/hour (risk of over-drainage, collapse of ventricles, hemorrhage)
-
Immediate ICP reduction; removes volume (CSF) from closed cranial compartment; critical for hydrocephalus; risk: infection, hemorrhage, over-drainage
-
STAT
-
STAT
Repeat osmotherapy dosing
-
-
0.25-0.5 g/kg :: - :: PRN :: Scheduled or PRN osmotherapy based on ICP readings; Mannitol: 0.25-0.5 g/kg q4-6h; HTS 3%: 30 mL/hr continuous or 250 mL bolus PRN; Monitor: Serum osm q4-6h (hold mannitol if >320); serum Na q2-4h (target 145-155 with HTS)
-
Sustained osmotherapy for sustained ICP elevation; alternating mannitol and HTS may extend treatment window; monitor for accumulation
-
STAT
-
STAT
Decompressive craniectomy
-
-
N/A :: - :: once :: Indications: Refractory ICP despite maximal medical therapy; malignant MCA stroke (large hemispheric infarct with edema); large ICH with mass effect; traumatic brain injury with refractory ICP; Timing: TBI: DECRA trial (2011) — early DC did not improve 6-mo outcomes but reduced ICP/ICU stay; RESCUEicp (2016) — late rescue DC improved survival but increased severe disability; Stroke: DESTINY/DECIMAL/HAMLET — DC improves survival in malignant MCA stroke age <60 (NNT=2); must discuss goals of care
-
Removes skull to allow brain expansion; definitive ICP reduction; increases survival but may increase proportion surviving with severe disability; requires extensive goals of care discussion; timing and patient selection critical
-
STAT
-
-
Dexamethasone (tumor/vasogenic edema)
IV
-
10 mg :: IV :: q6h :: ONLY for vasogenic edema from tumor or abscess; NOT for TBI, stroke, or cytotoxic edema (steroids worsen outcomes in TBI — CRASH trial); Dose: 10 mg IV load → 4 mg IV q6h; Duration: Until definitive tumor treatment; taper over 1-2 weeks after radiation/surgery; GI prophylaxis with PPI
-
Reduces vasogenic edema around tumors; inhibits VEGF; dramatic effect within 24-48h; CRASH trial: steroids HARMFUL in TBI — avoid; no benefit in stroke
-
STAT
ROUTINE
STAT
Surgical evacuation of mass lesion
-
-
30 mL :: - :: - :: Epidural hematoma: Emergent if >30 mL, >15mm thickness, or >5mm midline shift, or GCS deterioration; Subdural hematoma: Emergent if >10mm thickness, >5mm midline shift, or GCS decrease >2 points; ICH: Consider if lobar >30 mL and deteriorating; cerebellar >3cm or hydrocephalus; Tumor: Resection or debulking for mass effect
-
Removes compressive mass → immediate ICP reduction; life-saving for epidural hematoma; subdural and ICH outcomes less clearly improved by surgery but indicated for mass effect and herniation
5-10 mg/kg :: IV :: Continuous :: LAST RESORT for refractory ICP; Protocol: Pentobarbital 5-10 mg/kg IV load over 30 min → 1-3 mg/kg/hr infusion; titrate to ICP <22 mmHg or burst suppression on EEG; Target: Burst suppression (3-10 second bursts with 10-20 second suppression); Monitor: Continuous EEG; drug levels (30-50 mcg/mL); hemodynamics (causes hypotension — often need vasopressors); Duration: 24-48h then attempt to wean; may need 3-5 days
-
Reduces CMRO2 to minimal levels; dramatic ICP reduction; causes severe hypotension (need vasopressors); immunosuppression; ileus; prolonged sedation; no proven mortality benefit but reduces ICP; requires ICU expertise
-
-
-
STAT
Therapeutic hypothermia (rescue)
-
-
N/A :: - :: per protocol :: For refractory ICP only (NOT prophylactic); Target: 32-35°C; Method: Surface cooling (Arctic Sun) or intravascular cooling catheter; Duration: 24-72h; Rewarming: Slow — 0.25°C/hour (rapid rewarming causes ICP rebound); Complications: Shivering (treat with paralysis, buspirone, meperidine), coagulopathy, infection, arrhythmia
-
Reduces CMRO2 and ICP; EUROTHERM (2015): prophylactic hypothermia HARMFUL in TBI; rescue hypothermia for refractory ICP still used but evidence weak; prevents fever spikes; requires expertise
-
-
-
STAT
Lumbar CSF drainage
-
-
5-10 mL/h :: - :: - :: ONLY if: Communicating hydrocephalus; ICP refractory to EVD drainage; no mass lesion or obstructive hydrocephalus; basal cisterns visible; Method: Lumbar drain at 10-15 cm H2O; drain 5-10 mL/hour; Risk: Tonsillar herniation if used inappropriately; overdrainage
-
Drains CSF from lumbar space; reduces overall CSF volume; effective adjunct in communicating hydrocephalus; must NOT be used with obstructive hydrocephalus or significant mass effect
-
-
-
STAT
High-dose hypertonic saline (23.4%)
IV
-
30 mL :: IV :: once :: For refractory ICP crisis; 30 mL IV bolus via central line; can repeat; target sodium up to 155-160 mEq/L in refractory cases (with close monitoring); Risk: Central pontine myelinolysis if rapid sodium changes (maintain stable elevated sodium; do not rapidly correct back to normal)
-
Potent osmotherapy; can achieve higher sodium targets than 3% NaCl; reserved for refractory cases; requires central line access
-
-
-
STAT
Decompressive craniectomy (rescue)
-
-
26.9% :: - :: - :: As above; indicated for refractory ICP after failure of all medical therapies; must discuss survival with potential severe disability (RESCUEicp: DC improved survival from 26.9% to 48.9% but increased severe disability); goals of care critical
-
RESCUEicp (2016): More patients survived with DC but at cost of more survivors with severe disability; DECRA (2011): Early prophylactic DC did not improve functional outcomes; decision requires extensive patient/family discussion
ICP monitoring if GCS ≤8; CPP 60-70; avoid hypoxia (PaO2 <60), hypotension (SBP <90), hyperventilation (except acute herniation), hyperglycemia (>180), hyperthermia; seizure prophylaxis x 7 days; surgical evacuation of hematomas per criteria; decompressive craniectomy for refractory ICP
Malignant MCA Stroke
Decompressive craniectomy (hemicraniectomy) if age <60, within 48h; DESTINY/DECIMAL/HAMLET: NNT=2 for survival; discuss functional outcomes (many survive with hemiplegia, aphasia); no benefit from steroids; osmotherapy as bridge
Intracerebral Hemorrhage (ICH)
BP control (target SBP <140 per INTERACT2/ATACH-2); reverse anticoagulation; surgical evacuation if cerebellar >3cm, lobar >30mL with deterioration; EVD for hydrocephalus; no steroids
Subarachnoid Hemorrhage (SAH)
Secure aneurysm (clip/coil); nimodipine 60 mg q4h x 21 days; EVD for hydrocephalus; monitor for vasospasm (TCD, clinical); treat vasospasm (induced hypertension, intra-arterial therapy); euvolemia; avoid hypotension
Brain Tumor
Dexamethasone 10 mg IV then 4 mg q6h (for vasogenic edema); PPI while on steroids; surgical resection/debulking for mass effect; radiation/chemotherapy as appropriate; no osmotherapy needed if steroids effective
Brain Abscess
Antibiotics (empiric then targeted); surgical drainage (aspiration or excision) if >2.5 cm or refractory; dexamethasone for edema (controversial — may impair antibiotic penetration and immune response but used for severe edema); treat source
Meningitis
Antibiotics (empiric then targeted); dexamethasone 0.15 mg/kg q6h x 4 days for bacterial meningitis (give before or with first antibiotic dose — reduces inflammation); ICP management as above; EVD for hydrocephalus
Hydrocephalus
EVD (emergent temporizing measure); VP shunt (definitive for communicating); ETV (endoscopic third ventriculostomy for obstructive); treat underlying cause (tumor, hemorrhage, infection)
Idiopathic Intracranial Hypertension (IIH)
Weight loss (most important long-term intervention); acetazolamide 250 mg BID → titrate to 1-2 g/day (reduces CSF production); topiramate (weight loss + ICP reduction); furosemide (adjunct); serial LP (therapeutic drainage); optic nerve sheath fenestration (for vision loss); VP shunt or transverse sinus stenting (refractory)
Cerebral Venous Sinus Thrombosis (CVST)
Anticoagulation (heparin → warfarin or DOAC) even if hemorrhagic; ICP management as above; treat underlying hypercoagulable state; endovascular thrombectomy for refractory cases
All patients with elevated ICP need neurosurgical evaluation; ICP monitor/EVD placement; surgical decompression decisions; hematoma evacuation
Neuro-ICU admission
-
STAT
-
STAT
All patients with elevated ICP requiring intervention should be in Neuro-ICU or equivalent; 24/7 neuro-trained nursing; ICP monitoring capability; rapid imaging access
Continuous ICP monitoring (invasive)
-
STAT
-
STAT
If GCS ≤8 with abnormal CT; or GCS ≤8 with normal CT + risk factors; guides all ICP-directed therapy; allows CPP calculation
Continuous EtCO2 / frequent ABG
-
STAT
-
STAT
Ventilated patients: EtCO2 monitoring (correlate with ABG); target PaCO2 35-40; avoid hyperventilation except for acute crisis
Serial neurologic examination
STAT
STAT
-
STAT
q1-2h in unstable patients; pupil reactivity; GCS; motor response; detect early herniation; any decline → immediate intervention
Any patient requiring ICP monitoring; GCS ≤8; signs of herniation; requiring osmotherapy, sedation, or mechanical ventilation for ICP; post-operative after decompressive craniectomy or hematoma evacuation; status epilepticus; hemodynamic instability
Late/rescue DC for refractory ICP in TBI improved survival (48.9% vs. 26.9%) but increased proportion with severe disability; similar rates of favorable outcome
DC is life-saving but increases survival with disability; requires goals of care discussion
DC for malignant MCA stroke <60 years within 48h reduces mortality (NNT=2); higher survival with moderate-severe disability (mRS 4); DC should be offered
Standard of care for malignant MCA stroke in appropriate patients
Serum osm q4-6h; BMP q6h; Foley (massive diuresis)
HTS 23.4%
30 mL over 15-20 min
5-15 min
2-4 hr
Na >160 (relative)
Central line only
Na q2-4h; avoid rapid Na changes
HTS 3%
250-500 mL bolus or 30-50 mL/hr continuous
15-30 min
2-4 hr
Na >160 (relative)
Peripheral OK (central preferred)
Na q2-4h
HTS 2%
500-1000 mL bolus or continuous
30 min
2-4 hr
Na >160 (relative)
Peripheral OK
Na q4-6h
Key differences:
- Mannitol: Causes diuresis → may worsen hypovolemia; accumulates in brain with BBB disruption; renal toxicity with prolonged use; osmolar gap monitoring
- Hypertonic saline: No diuresis → better for hypovolemic patients; no osmolar gap ceiling; does not accumulate in brain; no renal toxicity; requires Na monitoring
SIGNS OF ACUTE HERNIATION
(Pupil dilation, posturing, Cushing triad, rapidly declining GCS)
│
IMMEDIATE ACTIONS (within minutes):
1. Call for help (neurosurgery STAT, airway team)
2. HOB to 30° (or reverse Trendelenburg if C-spine)
3. Hyperventilation if intubated: target PaCO2 30-35
(bag at 20 breaths/min; avoid PaCO2 <25)
4. Osmotherapy STAT:
• Mannitol 1-1.5 g/kg IV push (100g = 500 mL of 20%)
OR
• 23.4% NaCl 30 mL IV via central line over 10-15 min
OR
• 3% NaCl 500 mL rapid infusion if no central access
5. STAT CT head (if not already done)
6. Prepare for emergent surgical intervention
│
THESE ARE BRIDGE THERAPIES
Definitive treatment = surgical decompression
(hematoma evacuation, DC, tumor resection, EVD)
Ketamine (controversial — may be safe in controlled ventilation)
Propofol
Volatile anesthetics (at high concentrations)
Barbiturates (thiopental, pentobarbital)
Nitroprusside
Etomidate
Succinylcholine (transient)
Benzodiazepines (mild)
Hypercapnia
Fentanyl, remifentanil
Hypoxia
Mannitol, hypertonic saline
Fever
Hypothermia
Seizures
Neuromuscular blockers (by preventing ICP spikes from posturing/coughing)
Valsalva, coughing, straining
Hyperventilation (transient — use with caution)
This template represents the initial build phase (Skill 1) and requires validation through the checker pipeline (Skills 2-6) before clinical deployment.