Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis
- Robert C Tasker, MBBS, MD
Robert C Tasker, MBBS, MD
- Professor of Neurology and Anaesthesia (Pediatrics)
- Harvard Medical School
- Section Editors
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- Marc C Patterson, MD, FRACP
Marc C Patterson, MD, FRACP
- Section Editor — Pediatric Neurology
- Professor of Neurology, Pediatrics, and Medical Genetics
- Chair, Division of Child and Adolescent Neurology
- Mayo Clinic College of Medicine
- Adrienne G Randolph, MD, MSc
Adrienne G Randolph, MD, MSc
- Section Editor — Pediatric Critical Care Medicine
- Professor of Anaesthesia and Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The clinical manifestations and diagnosis of elevated ICP in children will be reviewed here.
The management of elevated ICP in children, the evaluation of stupor and coma in children, and initial management of children with severe traumatic brain injury are discussed separately. (See "Elevated intracranial pressure (ICP) in children: Management" and "Evaluation of stupor and coma in children" and "Severe traumatic brain injury in children: Initial evaluation and management".)
Elevated ICP is a potentially devastating complication of neurologic injury. In children, increased ICP is most often a complication of traumatic brain injury; it may also occur in children who have hydrocephalus, brain tumors, intracranial infections, hepatic encephalopathy, or impaired central nervous system venous outflow (table 1). Successful management of children with elevated ICP requires prompt recognition and therapy directed at both reducing ICP and reversing its underlying cause. Early recognition of elevated ICP can prevent neurologic sequelae and death.
Intracranial pressure — The range of normal cerebrospinal fluid (CSF) pressure in children (10th to 90th percentile) at the time of lumbar puncture is 12 to 28 cmH2O (9 to 21 mmHg) [1-3]. Measured ICP >20 mmHg (27 cmH2O) for longer than five minutes with signs or symptoms is generally regarded as the threshold for treatment . Occasional transient elevations may occur with physiologic events, including sneezing, coughing, or Valsalva maneuvers. However, sustained elevations above this pressure are abnormal .
The intracranial compartment is protected by the skull, a rigid structure with a fixed internal volume; the intracranial contents include (by volume) :
- Avery RA, Shah SS, Licht DJ, et al. Reference range for cerebrospinal fluid opening pressure in children. N Engl J Med 2010; 363:891.
- Avery RA. Interpretation of lumbar puncture opening pressure measurements in children. J Neuroophthalmol 2014; 34:284.
- Cartwright C, Igbaseimokumo U. Lumbar puncture opening pressure is not a reliable measure of intracranial pressure in children. J Child Neurol 2015; 30:170.
- Stevens RD, Shoykhet M, Cadena R. Emergency Neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care 2015; 23 Suppl 2:S76.
- Miller Ferguson N, Shein SL, Kochanek PM, et al. Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults. Pediatr Crit Care Med 2016; 17:444.
- Allen CH, Ward JD. An evidence-based approach to management of increased intracranial pressure. Crit Care Clin 1998; 14:485.
- Davson H, Hollingsworth G, Segal MB. The mechanism of drainage of the cerebrospinal fluid. Brain 1970; 93:665.
- Tasker RC. Intracranial pressure: influence of head-of-bed elevation, and beyond. Pediatr Crit Care Med 2012; 13:116.
- Monro A. Observations on the Structure and Functions of the Nervous System, Creech and Johnson, Edinburgh 1783.
- Kellie, G. An account of the appearances observed in the dissection of two of the individuals presumed to have perished in the storm of the third, and whose bodies were discovered in the vicinity of Leith on the morning of the 4th November 1821; with some reflections on the pathology of the brain. Trans Med Chir Soc (Edinburgh) 1821-1832;1:84.
- Jenkins LW, Kochanek PM. Developmental Neurobiology, Neurophysiology, and the PICU. In: Rogers’ Textbook of Pediatric Intensive Care, 5th ed, Nichols DG, Shaffner DH. (Eds), Lippincott Williams & Wilkins, Philadelphia 2015. p.861.
- Haque IU, Zaritsky AL. Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatr Crit Care Med 2007; 8:138.
- Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med 2012; 13 Suppl 1:S1.
- Pellerin L, Bouzier-Sore AK, Aubert A, et al. Activity-dependent regulation of energy metabolism by astrocytes: an update. Glia 2007; 55:1251.
- Bouma GJ, Muizelaar JP, Fatouros P. Pathogenesis of traumatic brain swelling: role of cerebral blood volume. Acta Neurochir Suppl 1998; 71:272.
- Tekes A, Poretti A, Scheurkogel MM, et al. Apparent diffusion coefficient scalars correlate with near-infrared spectroscopy markers of cerebrovascular autoregulation in neonates cooled for perinatal hypoxic-ischemic injury. AJNR Am J Neuroradiol 2015; 36:188.
- Aldrich EF, Eisenberg HM, Saydjari C, et al. Diffuse brain swelling in severely head-injured children. A report from the NIH Traumatic Coma Data Bank. J Neurosurg 1992; 76:450.
- Tasker RC, Acerini CL. Cerebral edema in children with diabetic ketoacidosis: vasogenic rather than cellular? Pediatr Diabetes 2014; 15:261.
- O'Brien NF, Maa T, Yeates KO. The epidemiology of vasospasm in children with moderate-to-severe traumatic brain injury. Crit Care Med 2015; 43:674.
- Posner JB, Saper CB, Schiff N, Plum F. Herniation syndromes: Intracranial shifts in the pathogenesis of coma. In: Plum and Posner's Diagnosis of Supor and Coma, 4th ed, Oxford University Press, New York 2007. p.95.
- Xu W, Gerety P, Aleman T, et al. Noninvasive methods of detecting increased intracranial pressure. Childs Nerv Syst 2016; 32:1371.
- Ho ML, Rojas R, Eisenberg RL. Cerebral edema. AJR Am J Roentgenol 2012; 199:W258.
- Padayachy LC, Padayachy V, Galal U, et al. The relationship between transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) and invasively measured ICP in children. : Part II: age-related ONSD cut-off values and patency of the anterior fontanelle. Childs Nerv Syst 2016; 32:1779.
- Bailey BM, Liesemer K, Statler KD, et al. Monitoring and prediction of intracranial hypertension in pediatric traumatic brain injury: clinical factors and initial head computed tomography. J Trauma Acute Care Surg 2012; 72:263.
- Tasker RC, Matthew DJ, Kendall B. Computed tomography in the assessment of raised intracranial pressure in non-traumatic coma. Neuropediatrics 1990; 21:91.
- Muehlmann M, Koerte IK, Laubender RP, et al. Magnetic resonance-based estimation of intracranial pressure correlates with ventriculoperitoneal shunt valve opening pressure setting in children with hydrocephalus. Invest Radiol 2013; 48:543.
- Leliefeld PH, Gooskens RH, Vincken KL, et al. Magnetic resonance imaging for quantitative flow measurement in infants with hydrocephalus: a prospective study. J Neurosurg Pediatr 2008; 2:163.
- Poca MA, Sahuquillo J, Busto M, et al. Agreement between CSF flow dynamics in MRI and ICP monitoring in the diagnosis of normal pressure hydrocephalus. Sensitivity and specificity of CSF dynamics to predict outcome. Acta Neurochir Suppl 2002; 81:7.
- Geeraerts T, Newcombe VF, Coles JP, et al. Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. Crit Care 2008; 12:R114.
- Rangwala LM, Liu GT. Pediatric idiopathic intracranial hypertension. Surv Ophthalmol 2007; 52:597.
- Nazir S, O'Brien M, Qureshi NH, et al. Sensitivity of papilledema as a sign of shunt failure in children. J AAPOS 2009; 13:63.
- Swanson JW, Aleman TS, Xu W, et al. Evaluation of Optical Coherence Tomography to Detect Elevated Intracranial Pressure in Children. JAMA Ophthalmol 2017; 135:320.
- Driessen C, Eveleens J, Bleyen I, et al. Optical coherence tomography: a quantitative tool to screen for papilledema in craniosynostosis. Childs Nerv Syst 2014; 30:1067.
- Tasker RC, Aboy M, Graham A, Goldstein B. Neurologic monitoring. In: Rogers' Textbook of Pediatric Intensive Care, 5th ed, Nichols DG, Shaffner DH (Eds), Wolters Kluwer, Philadelphia 2016. p.907.
- Intracranial pressure
- Cerebral perfusion pressure
- Cerebral blood flow
- Cerebral edema
- Brain herniation syndromes
- CLINICAL MANIFESTATIONS
- Patient age
- Acutely elevated ICP
- Subacutely or chronically elevated ICP
- Noninvasive detection of elevated ICP
- - Computed tomography
- - Magnetic resonance imaging
- - Detection of papilledema
- - Ocular ultrasound
- Invasive measurement of ICP
- Ancillary studies
- - Laboratory studies
- - Lumbar puncture
- - Electroencephalogram
- DIFFERENTIAL DIAGNOSIS
- Acute intracranial hypertension
- Chronic intracranial hypertension