Clinical Presentation

The clinical presentation of increased intracranial pressure can vary significantly depending on the underlying etiology, rate of progression, and severity. However, there are some common signs and symptoms that may indicate elevated ICP and prompt urgent evaluation and treatment.

• Headache – Often described as throbbing or diffuse, worsens with exertion or Valsalva. May be accompanied by nausea/vomiting. Can be the only symptom of chronically elevated ICP.
• Altered mental status – Manifests as confusion, drowsiness, or loss of consciousness. May fluctuate or progress rapidly. Concerning for cerebral herniation if associated with lateralizing neurologic deficits.
• Vision changes – Diplopia from cranial nerve palsies, blurry vision from papilledema. Patients may describe curtains/halos in their visual fields.
• Ataxia, dizziness – Results from compression of cerebellum or brainstem. Worrisome for impending herniation.
• Nausea/vomiting – Can be an early symptom, related to stimulation of the vomiting center in the medulla by pressure.
• Seizures – More common with rapidly increasing ICP.
• Focal neurological deficits – Weakness, sensory changes depending on localized effects of mass lesions or herniation syndromes.
• Cushing’s triad – Bradycardia, hypertension, irregular respiration is a late finding indicating impeded cerebral perfusion.

Risk Factors:

• Traumatic brain injury – Contusions, bleeds, or cerebral edema can manifest rapidly after injury
• ICH, SAH, AVM – Hemorrhagic strokes increase volume acutely
• Brain tumors – Mass effect or obstruction of CSF flow causes increased ICP
• CNS infections – Inflammation and edema related to meningitis/encephalitis
• Acute hydrocephalus – Intraventricular hemorrhage or meningitis prevents CSF absorption
• Hypertensive encephalopathy – Cerebral edema from failed autoregulation of blood flow
• Fulminant hepatic failure – Cytotoxic edema from accumulating ammonia and glutamine
• High altitude sickness – Hypoxemia leads to cerebral vasodilation and increased blood volume

Patients with acute neurological injuries or disorders affecting the brain are at highest risk. Increased ICP can occur at any age but is more common in adults. The clinical progression can vary from insidious headache to rapid neurological decline depending on the underlying process. Early recognition of signs and symptoms in at-risk patients is key to prevent further brain injury.