Olaru Cristiana, Langberg Sam, McCoin Nicole Streiff
Ochsner Health, Department of Emergency Medicine, New Orleans, Louisiana.
West J Emerg Med. 2024 Nov;25(6):1003-1010. doi: 10.5811/westjem.18500.
Increased intracranial pressure (ICP) is encountered in numerous traumatic and non-traumatic medical situations, and it requires immediate recognition and attention. Clinically, ICP typically presents with a headache that is most severe in the morning, aggravated by Valsalva-like maneuvers, and associated with nausea or vomiting. Papilledema is a well-recognized sign of increased ICP; however, emergency physicians often find it difficult to visualize the optic disc using ophthalmoscopy or to accurately interpret digital fundus photographs when using a non-mydriatic retinal camera. Emergency ultrasound can evaluate the optic nerve sheath diameter (ONSD) and optic disc elevation to determine whether increased ICP is present, however, the studies have been small with different definitions and measurements of the ONSD. The ONSD threshold values for increased ICP have been reported anywhere from 4.8 to 6.3 millimeters. Neuroimaging is the next step in the evaluation of patients with papilledema or high clinical suspicion of increased ICP, as it can identify most structural causes or typical radiological patterns of increased ICP. Neuroradiographic signs of increased ICP can be helpful in suggesting idiopathic intracranial hypertension (IIH), especially when papilledema is absent. Patients with papilledema and normal neuroimaging may undergo lumbar puncture as part of their clinical workup. The cerebrospinal fluid (CSF) opening pressure remains one of the most important investigations to establish the diagnosis of IIH. A CSF evaluation is also required to exclude other etiologies of elevated ICP such as infectious, inflammatory, and neoplastic meningitis. Invasive ICP measurement remains the standard to measure and monitor this condition.
颅内压（ICP）升高在众多创伤性和非创伤性医疗情况下都会出现，需要立即识别并引起关注。临床上，ICP通常表现为早晨最为严重的头痛，类似瓦尔萨尔瓦动作会使其加重，并伴有恶心或呕吐。视乳头水肿是公认的ICP升高的体征；然而，急诊医生常常难以通过检眼镜观察到视盘，或者在使用非散瞳视网膜相机时难以准确解读数字眼底照片。急诊超声可以评估视神经鞘直径（ONSD）和视盘隆起，以确定是否存在ICP升高，不过，相关研究规模较小，且对ONSD的定义和测量方法各不相同。据报道，ICP升高时ONSD的阈值在4.8至6.3毫米之间。对于有视乳头水肿或高度怀疑ICP升高的患者，下一步评估是进行神经影像学检查，因为它可以识别大多数ICP升高的结构原因或典型放射学模式。ICP升高的神经影像学征象有助于提示特发性颅内高压（IIH），尤其是在没有视乳头水肿的情况下。有视乳头水肿且神经影像学检查正常的患者，在临床检查中可能会进行腰椎穿刺。脑脊液（CSF）初压仍然是确立IIH诊断的最重要检查之一。还需要进行脑脊液评估以排除ICP升高的其他病因，如感染性、炎症性和肿瘤性脑膜炎。有创ICP测量仍然是测量和监测这种情况的标准方法。
