Timing of neurosurgical interventions for intracranial hypertension: the intensivists’ and neurosurgeons’ view

Purpose of review The aim of this study was to highlight clinical considerations regarding medical versus surgical management of elevated intracranial pressure (ICP), describe limitations of medical management, and summarize evidence regarding timing of neurosurgical interventions. Recent findings The optimal ICP management strategy remains elusive, and substantial practice variations exist. Common risks of medical treatments include hypotension/shock, cardiac arrhythmias and heart failure, acute renal failure, volume overload, hypoxemia, and prolonged mechanical ventilation. In traumatic brain injury (TBI), recent randomized controlled trials (RCT) did not demonstrate outcome benefits for early, prophylactic decompressive craniectomy, but indicate a role for secondary decompressive craniectomy in patients with refractory elevated ICP. A recent meta-analysis suggested that when an extraventricular drain is required, insertion 24 h or less post-TBI may result in better outcomes. In large ischemic middle cerebral artery strokes, pooled analyses of three RCTs showed functional outcome benefits in patients less than 60 years who underwent prophylactic DC within less than 48 h. In intracranial hemorrhage, a recent RCT suggested outcome benefits for minimally invasive hematoma evacuation within less than 24 h. Summary More data are needed to guide ICP targets, treatment modalities, predictors of herniation, and surgical triggers; clinical decisions should consider individual patient characteristics, and account for risks of medical and surgical treatments.