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Evaluation and management of elevated intracranial pressure in adults

Edward R Smith, MD
Sepideh Amin-Hanjani, MD
Section Editor
Michael J Aminoff, MD, DSc
Deputy Editor
Janet L Wilterdink, MD


Elevated intracranial pressure (ICP) is a potentially devastating complication of neurologic injury. Elevated ICP may complicate trauma, central nervous system (CNS) tumors, hydrocephalus, hepatic encephalopathy, and impaired CNS venous outflow (table 1) [1]. Successful management of patients with elevated ICP requires prompt recognition, the judicious use of invasive monitoring, and therapy directed at both reducing ICP and reversing its underlying cause.

The evaluation and management of adult patients with elevated ICP will be reviewed here. Elevated intracranial pressure in children and specific causes and complications of elevated ICP (eg, ischemic stroke, intracerebral hemorrhage, traumatic brain injury) are discussed separately. (See "Elevated intracranial pressure (ICP) in children" and "Management of acute severe traumatic brain injury", section on 'Intracranial pressure' and "Initial assessment and management of acute stroke" and "Spontaneous intracerebral hemorrhage: Treatment and prognosis" and "Treatment of aneurysmal subarachnoid hemorrhage", section on 'Management of complications'.)


Intracranial pressure is normally ≤15 mmHg in adults, and pathologic intracranial hypertension (ICH) is present at pressures ≥20 mmHg. ICP is normally lower in children than adults, and may be subatmospheric in newborns [2]. Homeostatic mechanisms stabilize ICP, with occasional transient elevations associated with physiologic events, including sneezing, coughing, or Valsalva maneuvers.

Intracranial components — In adults, the intracranial compartment is protected by the skull, a rigid structure with a fixed internal volume of 1400 to 1700 mL. Under physiologic conditions, the intracranial contents include (by volume) [3]:

  • Brain parenchyma — 80 percent
  • Cerebrospinal fluid — 10 percent
  • Blood — 10 percent


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