How is intracranial pressure monitored in patients with encephalopathy and acute liver failure (ALF)?

Updated: Jun 13, 2019
  • Author: Gagan K Sood, MD; Chief Editor: BS Anand, MD  more...
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Answer

Intracranial pressure monitoring

In patients with grade III or IV encephalopathy, consider placement of an ICP monitor. ICP monitoring helps in the early recognition of cerebral edema.

The clinical signs of elevated ICP, including hypertension, bradycardia, and irregular respirations (Cushing triad), are not uniformly present; these and other neurologic changes, such as papillary dilatation or signs of decerebration, are typically evident only late in the course. Computed tomography (CT) scanning of the brain does not reliably detect edema, especially in the early stages.

The primary purpose of ICP monitoring is to detect elevations in ICP and reductions in cerebral perfusion pressure (CPP; calculated as mean arterial pressure [MAP] minus ICP) so that interventions can be made to prevent herniation while preserving brain perfusion. The ultimate goal of such measures is to maintain neurologic integrity and to prolong survival while awaiting the receipt of a donor organ or recovery of sufficient functioning hepatocyte mass. Additionally, refractory ICH and/or decreased CPP are considered contraindications to liver transplantation in many centers.

If an ICP monitor is placed, ICP should be maintained below 20-25 mm Hg, if possible, with CPP maintained above 50-60 mm Hg. Support of systemic blood pressure may be required to maintain adequate CPP.


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