Management of Elevated Intracranial Pressure in Intracerebral Hemorrhage

Initial Conservative Measures

The American Heart Association recommends elevating the head of the bed to 30 degrees with the head in midline position to improve jugular venous outflow and lower ICP in patients with intracerebral hemorrhage 1, 2
The American Heart Association suggests correcting factors that exacerbate swelling, such as hypoxemia, hypercarbia, and hyperthermia, immediately in patients with intracerebral hemorrhage 4, 3
The American Heart Association recommends restricting free water to avoid hypo-osmolar fluids that worsen cerebral edema in patients with intracerebral hemorrhage 4, 3
The American Heart Association advises avoiding antihypertensive agents that cause cerebral vasodilation, such as sodium nitroprusside, in patients with intracerebral hemorrhage 4, 3

The American Heart Association suggests that fiberoptic ICP monitors or ventricular catheters are preferentially used in patients with high suspicion of elevated ICP or clinical deterioration 1, 2
The American Heart Association recommends targeting ICP <20-25 mm Hg and maintaining cerebral perfusion pressure (CPP) >50-60 mm Hg, ideally >70 mm Hg, in patients with intracerebral hemorrhage 5, 2
The American Heart Association notes that no randomized controlled trial has demonstrated efficacy of ICP monitoring in intracerebral hemorrhage, but it provides crucial physiological information 1, 2

The American Heart Association recommends mannitol 0.25-0.5 g/kg IV administered over 20 minutes, repeated every 6 hours as needed, as the primary osmotic agent for elevated ICP in patients with intracerebral hemorrhage 4, 3
The American Heart Association suggests that hypertonic saline (3% or 23.4% NaCl) is an effective alternative to mannitol and may provide longer duration of ICP control in patients with intracerebral hemorrhage 6
The American Heart Association notes that despite emerging evidence favoring hypertonic saline, no RCTs have demonstrated superiority over mannitol for clinical outcomes in intracerebral hemorrhage specifically 6

The American Heart Association suggests that ventriculostomy with CSF drainage is effective for lowering ICP, particularly with hydrocephalus, in patients with refractory elevated ICP 1
The American Heart Association recommends decompressive suboccipital craniectomy for cerebellar swelling with brainstem compression in patients with refractory elevated ICP 4, 3
The American Heart Association suggests that decompressive craniectomy may be considered for refractory intracranial hypertension in patients with supratentorial intracerebral hemorrhage 6

The American Heart Association advises against the use of hyperventilation, corticosteroids, furosemide, prophylactic hypothermia, and barbiturates in the management of elevated ICP in patients with intracerebral hemorrhage 4, 6, 3, 1, 2

The American Heart Association suggests that CPP-guided therapy targeting CPP >70 mm Hg is a popular approach, though concern exists that blood pressure elevation to maintain CPP may worsen intracranial hypertension in patients with intracerebral hemorrhage 1, 2
The American Heart Association recommends maintaining adequate intravascular volume before initiating vasopressors in patients with intracerebral hemorrhage 7