Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

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: Clinical manifestations and diagnosis" and "Management of acute severe traumatic brain injury", section on 'Intracranial pressure' and "Initial assessment and management of acute stroke" and "Treatment of aneurysmal subarachnoid hemorrhage", section on 'Management of complications' and "Spontaneous intracerebral hemorrhage: Treatment and prognosis", section on 'Intracranial pressure'.)


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

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jun 21, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Adams RA, Ropper AH.. Principles of neurology, 6th, McGraw Hill, New York 1997.
  2. Welch K. The intracranial pressure in infants. J Neurosurg 1980; 52:693.
  3. Kaye AH. Brain Tumors: An Encyclopedic Approach, 2nd, Churchill Livingstone, New York 2001. p.205.
  4. Monro A. Observations in the structure and functions of the nervous system, Creech and Johnson, Edinburgh 1783.
  5. Kellie G. An account of the appearence 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 24th, November 1821; with some reflections on the pathology of the brain. Trans Med Chir Soc (Edinburgh) 1821- 1832; 1:84.
  6. Fishman R. Cerebrospinal fluid in diseases of the nervous system, WB Saunders, Philadelphia 1980.
  7. Bruce DA, Alavi A, Bilaniuk L, et al. Diffuse cerebral swelling following head injuries in children: the syndrome of "malignant brain edema". J Neurosurg 1981; 54:170.
  8. 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.
  9. Levin HS, Aldrich EF, Saydjari C, et al. Severe head injury in children: experience of the Traumatic Coma Data Bank. Neurosurgery 1992; 31:435.
  10. Wilkins RS. Neurosurgery, 2nd, McGraw-Hill, New York 1996. Vol 1, p.347.
  11. Strandgaard S, Paulson OB. Cerebral blood flow and its pathophysiology in hypertension. Am J Hypertens 1989; 2:486.
  12. Strandgaard S, Andersen GS, Ahlgreen P, Nielsen PE. Visual disturbances and occipital brain infarct following acute, transient hypotension in hypertensive patients. Acta Med Scand 1984; 216:417.
  13. Enevoldsen EM, Jensen FT. Autoregulation and CO2 responses of cerebral blood flow in patients with acute severe head injury. J Neurosurg 1978; 48:689.
  14. Lassen NA, Agnoli A. The upper limit of autoregulation of cerebral blood flow--on the pathogenesis of hypertensive encepholopathy. Scand J Clin Lab Invest 1972; 30:113.
  15. Kaplan NM. Management of hypertensive emergencies. Lancet 1994; 344:1335.
  16. Hadjikoutis S, Carroll C, Plant GT. Raised intracranial pressure presenting with spontaneous periorbital bruising: two case reports. J Neurol Neurosurg Psychiatry 2004; 75:1192.
  17. Plum F Posner J. The Diagnosis of Stupor and Coma, 3rd, FA Davis, Philadelphia 1980.
  18. Kernohan JW. Incisura of the crus due to contralateral brain tumor. Arch Neurol Psychiatry 1929; 21:274.
  19. Binder DK, Lyon R, Manley GT. Transcranial motor evoked potential recording in a case of Kernohan's notch syndrome: case report. Neurosurgery 2004; 54:999.
  20. Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 1995; 83:949.
  21. Lane PL, Skoretz TG, Doig G, Girotti MJ. Intracranial pressure monitoring and outcomes after traumatic brain injury. Can J Surg 2000; 43:442.
  22. Bulger EM, Nathens AB, Rivara FP, et al. Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med 2002; 30:1870.
  23. Mauritz W, Steltzer H, Bauer P, et al. Monitoring of intracranial pressure in patients with severe traumatic brain injury: an Austrian prospective multicenter study. Intensive Care Med 2008; 34:1208.
  24. Marik PE, Varon J, Trask T. Management of head trauma. Chest 2002; 122:699.
  25. Bullock R, Chesnut RM, Clifton G.. Guidelines for the Management of Severe Brain Injury New York: Brain trauma foundation/American Association of Neurologic Surgeons, 1995.
  26. Dennis LJ, Mayer SA. Diagnosis and management of increased intracranial pressure. Neurol India 2001; 49 Suppl 1:S37.
  27. Eisenberg HM, Gary HE Jr, Aldrich EF, et al. Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg 1990; 73:688.
  28. O'Sullivan MG, Statham PF, Jones PA, et al. Role of intracranial pressure monitoring in severely head-injured patients without signs of intracranial hypertension on initial computerized tomography. J Neurosurg 1994; 80:46.
  29. Lobato RD, Sarabia R, Rivas JJ, et al. Normal computerized tomography scans in severe head injury. Prognostic and clinical management implications. J Neurosurg 1986; 65:784.
  30. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. VII. Intracranial pressure monitoring technology. J Neurotrauma 2007; 24 Suppl 1:S45.
  31. Mayhall CG, Archer NH, Lamb VA, et al. Ventriculostomy-related infections. A prospective epidemiologic study. N Engl J Med 1984; 310:553.
  32. Holloway KL, Barnes T, Choi S, et al. Ventriculostomy infections: the effect of monitoring duration and catheter exchange in 584 patients. J Neurosurg 1996; 85:419.
  33. Ghajar J. Intracranial pressure monitoring techniques. New Horiz 1995; 3:395.
  34. Ostrup RC, Luerssen TG, Marshall LF, Zornow MH. Continuous monitoring of intracranial pressure with a miniaturized fiberoptic device. J Neurosurg 1987; 67:206.
  35. Gambardella G, d'Avella D, Tomasello F. Monitoring of brain tissue pressure with a fiberoptic device. Neurosurgery 1992; 31:918.
  36. Bochicchio M, Latronico N, Zappa S, et al. Bedside burr hole for intracranial pressure monitoring performed by intensive care physicians. A 5-year experience. Intensive Care Med 1996; 22:1070.
  37. Poca MA, Sahuquillo J, Arribas M, et al. Fiberoptic intraparenchymal brain pressure monitoring with the Camino V420 monitor: reflections on our experience in 163 severely head-injured patients. J Neurotrauma 2002; 19:439.
  38. Piper I, Barnes A, Smith D, Dunn L. The Camino intracranial pressure sensor: is it optimal technology? An internal audit with a review of current intracranial pressure monitoring technologies. Neurosurgery 2001; 49:1158.
  39. Miller JD, Bobo H, Kapp JP. Inaccurate pressure readings for subarachnoid bolts. Neurosurgery 1986; 19:253.
  40. Blei AT, Olafsson S, Webster S, Levy R. Complications of intracranial pressure monitoring in fulminant hepatic failure. Lancet 1993; 341:157.
  41. Hayashi M, Handa Y, Kobayashi H, et al. Plateau-wave phenomenon (I). Correlation between the appearance of plateau waves and CSF circulation in patients with intracranial hypertension. Brain 1991; 114 ( Pt 6):2681.
  42. Rosner MJ, Becker DP. Origin and evolution of plateau waves. Experimental observations and a theoretical model. J Neurosurg 1984; 60:312.
  43. Manno EM. Transcranial Doppler ultrasonography in the neurocritical care unit. Crit Care Clin 1997; 13:79.
  44. Edouard AR, Vanhille E, Le Moigno S, et al. Non-invasive assessment of cerebral perfusion pressure in brain injured patients with moderate intracranial hypertension. Br J Anaesth 2005; 94:216.
  45. Hassler W, Steinmetz H, Gawlowski J. Transcranial Doppler ultrasonography in raised intracranial pressure and in intracranial circulatory arrest. J Neurosurg 1988; 68:745.
  46. Aaslid R, Markwalder TM, Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 1982; 57:769.
  47. Tan H, Feng H, Gao L, et al. Outcome prediction in severe traumatic brain injury with transcranial Doppler ultrasonography. Chin J Traumatol 2001; 4:156.
  48. Kristiansson H, Nissborg E, Bartek J Jr, et al. Measuring elevated intracranial pressure through noninvasive methods: a review of the literature. J Neurosurg Anesthesiol 2013; 25:372.
  49. Michaeli D, Rappaport ZH. Tissue resonance analysis; a novel method for noninvasive monitoring of intracranial pressure. Technical note. J Neurosurg 2002; 96:1132.
  50. Soldatos T, Karakitsos D, Chatzimichail K, et al. Optic nerve sonography in the diagnostic evaluation of adult brain injury. Crit Care 2008; 12:R67.
  51. Moretti R, Pizzi B, Cassini F, Vivaldi N. Reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial hemorrhage. Neurocrit Care 2009; 11:406.
  52. Moretti R, Pizzi B. Optic nerve ultrasound for detection of intracranial hypertension in intracranial hemorrhage patients: confirmation of previous findings in a different patient population. J Neurosurg Anesthesiol 2009; 21:16.
  53. Dubourg J, Javouhey E, Geeraerts T, et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med 2011; 37:1059.
  54. Geeraerts T, Launey Y, Martin L, et al. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med 2007; 33:1704.
  55. Geeraerts T, Merceron S, Benhamou D, et al. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 2008; 34:2062.
  56. Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008; 15:201.
  57. Lashutka MK, Chandra A, Murray HN, et al. The relationship of intraocular pressure to intracranial pressure. Ann Emerg Med 2004; 43:585.
  58. Sheeran P, Bland JM, Hall GM. Intraocular pressure changes and alterations in intracranial pressure. Lancet 2000; 355:899.
  59. Han Y, McCulley TJ, Horton JC. No correlation between intraocular pressure and intracranial pressure. Ann Neurol 2008; 64:221.
  60. Kirk T, Jones K, Miller S, Corbett J. Measurement of intraocular and intracranial pressure: is there a relationship? Ann Neurol 2011; 70:323.
  61. Kast R. A new method for noninvasive measurement of short-term cerebrospinal fluid pressure changes in humans. J Neurol 1985; 232:260.
  62. Reid A, Marchbanks RJ, Bateman DE, et al. Mean intracranial pressure monitoring by a non-invasive audiological technique: a pilot study. J Neurol Neurosurg Psychiatry 1989; 52:610.
  63. Procaccio F, Stocchetti N, Citerio G, et al. Guidelines for the treatment of adults with severe head trauma (part I). Initial assessment; evaluation and pre-hospital treatment; current criteria for hospital admission; systemic and cerebral monitoring. J Neurosurg Sci 2000; 44:1.
  64. Procaccio F, Stocchetti N, Citerio G, et al. Guidelines for the treatment of adults with severe head trauma (part II). Criteria for medical treatment. J Neurosurg Sci 2000; 44:11.
  65. Davella D, Brambilla GL, Delfini R, et al. Guidelines for the treatment of adults with severe head trauma (part III). Criteria for surgical treatment. J Neurosurg Sci 2000; 44:19.
  66. Robinson N, Clancy M. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg Med J 2001; 18:453.
  67. Smith ER, Madsen JR. Neurosurgical aspects of critical care neurology. Semin Pediatr Neurol 2004; 11:169.
  68. Smith ER, Madsen JR. Cerebral pathophysiology and critical care neurology: basic hemodynamic principles, cerebral perfusion, and intracranial pressure. Semin Pediatr Neurol 2004; 11:89.
  69. Bullock, R, Clifton G. Guidelines for the Management of Severe Brain Injury, Brain trauma foundation/American Association of Neurologic Surgeons, New York 1995.
  70. Schmoker JD, Shackford SR, Wald SL, Pietropaoli JA. An analysis of the relationship between fluid and sodium administration and intracranial pressure after head injury. J Trauma 1992; 33:476.
  71. Tranmer BI, Iacobacci RI, Kindt GW. Effects of crystalloid and colloid infusions on intracranial pressure and computerized electroencephalographic data in dogs with vasogenic brain edema. Neurosurgery 1989; 25:173.
  72. SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 2007; 357:874.
  73. Lassen NA, Christensen MS. Physiology of cerebral blood flow. Br J Anaesth 1976; 48:719.
  74. Rosner MJ, Coley IB. Cerebral perfusion pressure, intracranial pressure, and head elevation. J Neurosurg 1986; 65:636.
  75. Durward QJ, Amacher AL, Del Maestro RF, Sibbald WJ. Cerebral and cardiovascular responses to changes in head elevation in patients with intracranial hypertension. J Neurosurg 1983; 59:938.
  76. Busija DW, Leffler CW, Pourcyrous M. Hyperthermia increases cerebral metabolic rate and blood flow in neonatal pigs. Am J Physiol 1988; 255:H343.
  77. Murray MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 2002; 30:142.
  78. Lassen NA. Control of cerebral circulation in health and disease. Circ Res 1974; 34:749.
  79. Gabor AJ, Brooks AG, Scobey RP, Parsons GH. Intracranial pressure during epileptic seizures. Electroencephalogr Clin Neurophysiol 1984; 57:497.
  80. Bell BA, Smith MA, Kean DM, et al. Brain water measured by magnetic resonance imaging. Correlation with direct estimation and changes after mannitol and dexamethasone. Lancet 1987; 1:66.
  81. Millson C, James HE, Shapiro HM, Laurin R. Intracranial hypertension and brain oedema in albino rabbits. Part 2: Effects of acute therapy with diuretics. Acta Neurochir (Wien) 1981; 56:167.
  82. Nath F, Galbraith S. The effect of mannitol on cerebral white matter water content. J Neurosurg 1986; 65:41.
  83. Paczynski RP. Osmotherapy. Basic concepts and controversies. Crit Care Clin 1997; 13:105.
  84. Jafar JJ, Johns LM, Mullan SF. The effect of mannitol on cerebral blood flow. J Neurosurg 1986; 64:754.
  85. Kaufmann AM, Cardoso ER. Aggravation of vasogenic cerebral edema by multiple-dose mannitol. J Neurosurg 1992; 77:584.
  86. Polderman KH, van de Kraats G, Dixon JM, et al. Increases in spinal fluid osmolarity induced by mannitol. Crit Care Med 2003; 31:584.
  87. Cooper DJ, Myles PS, McDermott FT, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA 2004; 291:1350.
  88. Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of hypertonic (10%) saline in patients with raised intracranial pressure after stroke. Stroke 2002; 33:136.
  89. Munar F, Ferrer AM, de Nadal M, et al. Cerebral hemodynamic effects of 7.2% hypertonic saline in patients with head injury and raised intracranial pressure. J Neurotrauma 2000; 17:41.
  90. Suarez JI, Qureshi AI, Bhardwaj A, et al. Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med 1998; 26:1118.
  91. Shackford SR, Bourguignon PR, Wald SL, et al. Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial. J Trauma 1998; 44:50.
  92. Lescot T, Degos V, Zouaoui A, et al. Opposed effects of hypertonic saline on contusions and noncontused brain tissue in patients with severe traumatic brain injury. Crit Care Med 2006; 34:3029.
  93. Koenig MA, Bryan M, Lewin JL 3rd, et al. Reversal of transtentorial herniation with hypertonic saline. Neurology 2008; 70:1023.
  94. Francony G, Fauvage B, Falcon D, et al. Equimolar doses of mannitol and hypertonic saline in the treatment of increased intracranial pressure. Crit Care Med 2008; 36:795.
  95. Ware ML, Nemani VM, Meeker M, et al. Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury: a preliminary study. Neurosurgery 2005; 57:727.
  96. Lewandowski-Belfer JJ, Patel AV, Darracott RM, et al. Safety and efficacy of repeated doses of 14.6 or 23.4 % hypertonic saline for refractory intracranial hypertension. Neurocrit Care 2014; 20:436.
  97. Battison C, Andrews PJ, Graham C, Petty T. Randomized, controlled trial on the effect of a 20% mannitol solution and a 7.5% saline/6% dextran solution on increased intracranial pressure after brain injury. Crit Care Med 2005; 33:196.
  98. Vialet R, Albanèse J, Thomachot L, et al. Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Crit Care Med 2003; 31:1683.
  99. Schwarz S, Schwab S, Bertram M, et al. Effects of hypertonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke. Stroke 1998; 29:1550.
  100. Ichai C, Armando G, Orban JC, et al. Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain-injured patients. Intensive Care Med 2009; 35:471.
  101. Kamel H, Navi BB, Nakagawa K, et al. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med 2011; 39:554.
  102. Mortazavi MM, Romeo AK, Deep A, et al. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. J Neurosurg 2012; 116:210.
  103. Bhardwaj A, Ulatowski JA. Hypertonic saline solutions in brain injury. Curr Opin Crit Care 2004; 10:126.
  104. Hinson HE, Stein D, Sheth KN. Hypertonic saline and mannitol therapy in critical care neurology. J Intensive Care Med 2013; 28:3.
  105. Pollay M, Fullenwider C, Roberts PA, Stevens FA. Effect of mannitol and furosemide on blood-brain osmotic gradient and intracranial pressure. J Neurosurg 1983; 59:945.
  106. Wilkinson HA, Rosenfeld SR. Furosemide and mannitol in the treatment of acute experimental intracranial hypertension. Neurosurgery 1983; 12:405.
  107. Chesnut RM, Marshall LF. Management of head injury. Treatment of abnormal intracranial pressure. Neurosurg Clin N Am 1991; 2:267.
  108. García-Sola R, Pulido P, Capilla P. The immediate and long-term effects of mannitol and glycerol. A comparative experimental study. Acta Neurochir (Wien) 1991; 109:114.
  109. Node Y, Nakazawa S. Clinical study of mannitol and glycerol on raised intracranial pressure and on their rebound phenomenon. Adv Neurol 1990; 52:359.
  110. Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 2004; 364:1321.
  111. Edwards P, Arango M, Balica L, et al. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet 2005; 365:1957.
  112. McLone D. Pediatric Neurosurgery: Surgery of the Developing Nervous System, 4th, W.B. Saunders, Philadelphia 2001. p.626.
  113. Muizelaar JP, Marmarou A, Ward JD, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 1991; 75:731.
  114. Hoff JT. Cerebral protection. J Neurosurg 1986; 65:579.
  115. Laffey JG, Kavanagh BP. Hypocapnia. N Engl J Med 2002; 347:43.
  116. Yundt KD, Diringer MN. The use of hyperventilation and its impact on cerebral ischemia in the treatment of traumatic brain injury. Crit Care Clin 1997; 13:163.
  117. Stocchetti N, Maas AI, Chieregato A, van der Plas AA. Hyperventilation in head injury: a review. Chest 2005; 127:1812.
  118. Marion DW, Puccio A, Wisniewski SR, et al. Effect of hyperventilation on extracellular concentrations of glutamate, lactate, pyruvate, and local cerebral blood flow in patients with severe traumatic brain injury. Crit Care Med 2002; 30:2619.
  119. Coles JP, Minhas PS, Fryer TD, et al. Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates. Crit Care Med 2002; 30:1950.
  120. Imberti R, Bellinzona G, Langer M. Cerebral tissue PO2 and SjvO2 changes during moderate hyperventilation in patients with severe traumatic brain injury. J Neurosurg 2002; 96:97.
  121. Lafferty JJ, Keykhah MM, Shapiro HM, et al. Cerebral hypometabolism obtained with deep pentobarbital anesthesia and hypothermia (30 C). Anesthesiology 1978; 49:159.
  122. Marshall LF, Shapiro HM, Rauscher A, Kaufman NM. Pentobarbital therapy for intracranial hypertension in metabolic coma. Reye's syndrome. Crit Care Med 1978; 6:1.
  123. Messeter K, Nordström CH, Sundbärg G, et al. Cerebral hemodynamics in patients with acute severe head trauma. J Neurosurg 1986; 64:231.
  124. Nordström CH, Messeter K, Sundbärg G, et al. Cerebral blood flow, vasoreactivity, and oxygen consumption during barbiturate therapy in severe traumatic brain lesions. J Neurosurg 1988; 68:424.
  125. Marshall LF, Smith RW, Shapiro HM. The outcome with aggressive treatment in severe head injuries. Part II: acute and chronic barbiturate administration in the management of head injury. J Neurosurg 1979; 50:26.
  126. Rea GL, Rockswold GL. Barbiturate therapy in uncontrolled intracranial hypertension. Neurosurgery 1983; 12:401.
  127. Eisenberg HM, Frankowski RF, Contant CF, et al. High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 1988; 69:15.
  128. Ward JD, Becker DP, Miller JD, et al. Failure of prophylactic barbiturate coma in the treatment of severe head injury. J Neurosurg 1985; 62:383.
  129. Ng SY, Chin KJ, Kwek TK. Dyskalaemia associated with thiopentone barbiturate coma for refractory intracranial hypertension: a case series. Intensive Care Med 2011; 37:1285.
  130. Wilkins RH RS. Neurosurgery, 2nd, McGraw-Hill, New York 1996. Vol 1, p.347.
  131. James HE, Langfitt TW, Kumar VS, Ghostine SY. Treatment of intracranial hypertension. Analysis of 105 consecutive, continuous recordings of intracranial pressure. Acta Neurochir (Wien) 1977; 36:189.
  132. Marion DW, Obrist WD, Carlier PM, et al. The use of moderate therapeutic hypothermia for patients with severe head injuries: a preliminary report. J Neurosurg 1993; 79:354.
  133. Shiozaki T, Sugimoto H, Taneda M, et al. Effect of mild hypothermia on uncontrollable intracranial hypertension after severe head injury. J Neurosurg 1993; 79:363.
  134. Shiozaki T, Sugimoto H, Taneda M, et al. Selection of severely head injured patients for mild hypothermia therapy. J Neurosurg 1998; 89:206.
  135. Mellergård P. Changes in human intracerebral temperature in response to different methods of brain cooling. Neurosurgery 1992; 31:671.
  136. McIntyre LA, Fergusson DA, Hébert PC, et al. Prolonged therapeutic hypothermia after traumatic brain injury in adults: a systematic review. JAMA 2003; 289:2992.
  137. Burkert W, Paver HD. [Decompressive trepanation in therapy refractory brain edema]. Zentralbl Neurochir 1988; 49:318.
  138. Burkert W, Plaumann H. [The value of large pressure-relieving trepanation in treatment of refractory brain edema. Animal experiment studies, initial clinical results]. Zentralbl Neurochir 1989; 50:106.
  139. Hatashita S, Hoff JT. The effect of craniectomy on the biomechanics of normal brain. J Neurosurg 1987; 67:573.
  140. Hatashita S, Hoff JT. Biomechanics of brain edema in acute cerebral ischemia in cats. Stroke 1988; 19:91.
  141. Rinaldi A, Mangiola A, Anile C, et al. Hemodynamic effects of decompressive craniectomy in cold induced brain oedema. Acta Neurochir Suppl (Wien) 1990; 51:394.
  142. Moody RA, Ruamsuke S, Mullan SF. An evaluation of decompression in experimental head injury. J Neurosurg 1968; 29:586.
  143. Gaab M, Knoblich OE, Fuhrmeister U, et al. Comparison of the effects of surgical decompression and resection of local edema in the therapy of experimental brain trauma. Investigation of ICP, EEG and cerebral metabolism in cats. Childs Brain 1979; 5:484.
  144. Dam Hieu P, Sizun J, Person H, Besson G. The place of decompressive surgery in the treatment of uncontrollable post-traumatic intracranial hypertension in children. Childs Nerv Syst 1996; 12:270.
  145. Gower DJ, Lee KS, McWhorter JM. Role of subtemporal decompression in severe closed head injury. Neurosurgery 1988; 23:417.
  146. Guerra WK, Gaab MR, Dietz H, et al. Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 1999; 90:187.
  147. Jourdan C, Convert J, Mottolese C, et al. [Evaluation of the clinical benefit of decompression hemicraniectomy in intracranial hypertension not controlled by medical treatment]. Neurochirurgie 1993; 39:304.
  148. Jaeger M, Soehle M, Meixensberger J. Effects of decompressive craniectomy on brain tissue oxygen in patients with intracranial hypertension. J Neurol Neurosurg Psychiatry 2003; 74:513.
  149. Carter BS, Ogilvy CS, Candia GJ, et al. One-year outcome after decompressive surgery for massive nondominant hemispheric infarction. Neurosurgery 1997; 40:1168.
  150. Polin RS, Shaffrey ME, Bogaev CA, et al. Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 1997; 41:84.
  151. Delashaw JB, Broaddus WC, Kassell NF, et al. Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke 1990; 21:874.
  152. Kondziolka D, Fazl M. Functional recovery after decompressive craniectomy for cerebral infarction. Neurosurgery 1988; 23:143.
  153. Schwab S, Steiner T, Aschoff A, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998; 29:1888.
  154. Hofmeijer J, van der Worp HB, Kappelle LJ. Treatment of space-occupying cerebral infarction. Crit Care Med 2003; 31:617.
  155. Pranesh MB, Dinesh Nayak S, Mathew V, et al. Hemicraniectomy for large middle cerebral artery territory infarction: outcome in 19 patients. J Neurol Neurosurg Psychiatry 2003; 74:800.
  156. Albanèse J, Leone M, Alliez JR, et al. Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year. Crit Care Med 2003; 31:2535.
  157. Diedler J, Sykora M, Blatow M, et al. Decompressive surgery for severe brain edema. J Intensive Care Med 2009; 24:168.
  158. Fields JD, Lansberg MG, Skirboll SL, et al. "Paradoxical" transtentorial herniation due to CSF drainage in the presence of a hemicraniectomy. Neurology 2006; 67:1513.
  159. Oyelese AA, Steinberg GK, Huhn SL, Wijman CA. Paradoxical cerebral herniation secondary to lumbar puncture after decompressive craniectomy for a large space-occupying hemispheric stroke: case report. Neurosurgery 2005; 57:E594; discussion E594.
  160. Sarov M, Guichard JP, Chibarro S, et al. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke 2010; 41:560.