Raised Intracranial Pressure in Children
On this page
Direct answer
Raised intracranial pressure in children is a sustained rise in pressure within the rigid cranial cavity, usually caused by a mass, hydrocephalus, meningitis, encephalitis or cerebral venous thrombosis. The Cushing triad of hypertension, bradycardia and irregular breathing is a late sign of brainstem compromise. Management aims to lower intracranial volume while protecting cerebral perfusion, and it always includes treating the underlying cause.
What you must remember
- Cushing triad: hypertension with widened pulse pressure, bradycardia and irregular respiration, a late sign of herniation risk.
- Papilloedema: swelling of the optic disc, which takes time to develop and may be absent in acute cases.
- Infant signs: bulging fontanelle, split sutures, rapid head growth and sunsetting eyes.
- Common causes: brain tumours, hydrocephalus, cerebral venous thrombosis, meningitis and head injury.
- Idiopathic intracranial hypertension: raised pressure without a lesion, which is seen mainly in obese adolescents.
- Head position: elevation to about 30 degrees with the neck in a neutral position to aid venous drainage.
- Osmotherapy: mannitol or 3% hypertonic saline lowers brain water when pressure is dangerously raised.
A stepwise approach to lowering pressure
Management of raised intracranial pressure aims to reduce the volume inside the skull while keeping cerebral perfusion adequate. The steps below move from simple measures to definitive treatment.
- Position the head: elevate the head to about 30 degrees with the neck neutral, avoiding tight collars or ties that compress the neck veins.
- Maintain perfusion: keep the child normothermic, normoxic and normoglycaemic, and avoid hypotension, since low perfusion worsens ischaemia.
- Use fluids carefully: choose isotonic fluids and avoid hypotonic solutions, which increase brain water and worsen oedema.
- Give osmotherapy: mannitol or hypertonic saline reduces brain water when pressure is dangerously raised, with sodium and osmolality monitored closely.
- Control seizures and fever: treat fits promptly and lower fever, because both raise cerebral metabolic demand and pressure.
- Drain CSF: an external ventricular drain relieves pressure in hydrocephalus and is placed with neurosurgical input.
- Treat the cause: surgical decompression or resection of a mass, antibiotics for meningitis, or anticoagulation for cerebral venous thrombosis.
Where the exam tries to catch you
Raised pressure questions often test the timing of signs and the safety of procedures.
- Trap: treating the Cushing triad as an early warning sign Correct: it is a late sign of brainstem compromise, so headache, vomiting and papilloedema should prompt action earlier.
- Trap: expecting papilloedema in every acute case Correct: optic disc swelling takes time to develop, so its absence does not exclude raised pressure.
- Trap: performing lumbar puncture before imaging in a child with a mass Correct: removing CSF can precipitate tonsillar herniation, so imaging comes first.
- Trap: using hypotonic fluids for maintenance in a child with raised pressure Correct: hypotonic fluids increase brain water, so isotonic fluids are preferred.
Frequently asked questions
What is the Cushing triad and why does it matter in children?
The Cushing triad is hypertension with widened pulse pressure, bradycardia and irregular respiration, reflecting brainstem compromise from raised intracranial pressure. It is a late sign, so it signals impending herniation rather than early disease in children.
Why is papilloedema often absent in acute raised intracranial pressure?
Papilloedema is often absent in acute raised intracranial pressure because optic disc swelling takes time to develop. Its absence therefore does not exclude raised pressure in a child with headache and vomiting.
Why should lumbar puncture be avoided before imaging in raised intracranial pressure?
Lumbar puncture should be avoided before imaging in raised intracranial pressure because removing CSF can precipitate tonsillar herniation through the foramen magnum. Imaging is done first to exclude a mass lesion or hydrocephalus.
Why are hypotonic fluids avoided in children with raised intracranial pressure?
Hypotonic fluids are avoided in children with raised intracranial pressure because they shift water into brain cells and increase cerebral oedema. Isotonic fluids are preferred, with sodium levels monitored carefully.
What head position is recommended to lower intracranial pressure?
Elevating the head to about 30 degrees with the neck in a neutral position is recommended to lower intracranial pressure, as it aids venous drainage. Tight collars or ties that compress the neck veins should be avoided.