Emergency Neurological Life Support: Intracranial Hypertension and Herniation

Abstract

Sustained intracranial hypertension and acute brain herniation are “brain codes,” signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this emergency neurological life support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation.

Management of intracranial hypertension: Recent advances and future directions

“…There are many methods that may be used in decreasing ICP and these treatment strategies have been stratified into tiers (Table 1). 5,6 These strategies will be briefly discussed below before reviewing the recent literature and reflecting on future prospects.…”

Maximal Medical Management: Pushing the Critical Envelope Further

“…However, in some conditions such as cerebral edema, the treatment remains primarily conservative. From a Neurocritical care perspective, there is much to be done to mitigate the intracranial hypertension related tocerebral edema from various etiologies, including stroke: for example, reduction in cerebral blood flow with anesthetics, increased venous drainage, hyperosmolar and hypertonic medications, and normo-or hypothermia [12].At our institution, we have taken maximal medical management of cytotoxic and vasogenic edema one step further and implemented a hospital-wide "Brain Code" system. This system was adopted in 2012, and is modeled after the now-familiar but once-revolutionary "Stroke Code" [13].…”

“…However, in some conditions such as cerebral edema, the treatment remains primarily conservative. From a Neurocritical care perspective, there is much to be done to mitigate the intracranial hypertension related tocerebral edema from various etiologies, including stroke: for example, reduction in cerebral blood flow with anesthetics, increased venous drainage, hyperosmolar and hypertonic medications, and normo-or hypothermia [12].…”

“…We need to be able to give these medications in the most timesensitive manner possible, and we are using the 'code' model to push the envelope and achieve faster administration. This system was suggested by the Emergency Neurological Life Support course [12] and called for by neurological academicians [15,16], but we are one of the first academic medical centers to have implemented a formalized brain code process. Using the Brain Code system, we can more effectively manage intracranial crises.…”

Efficacy Comparison of Mannitol and Hypertonic Saline for Traumatic Brain Injury (TBI) Treatment

“…10 In most intracranial hemorrhagic case, operation is definitive therapy in reducing ICP by evacuating hematoma.…”