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Rx of intracranial hypertension in CHF

Intracranial hypertension is the general term for any condition in which cerebrospinal fluid (CSF) pressure within the skull is too high (typically an intracranial pressure of >20mmHg).

The best treatment for intracranial hypertension is removal of the proximate cause of the elevated intracranial pressure, such as by CSF diversion in the setting of hydrocephalus. In addition to definitive therapy, many acute measures can be employed to reduce ICP. These may include hyperventilation, hyperosmotic therapy, sedation, blood pressure control, head positioning, and treatment of seizures or fever [1].

Care must be taken when treating intracranial hypertension in patients with congestive heart failure (CHF). Most notably, administration of hyperosmotic therapy (e.g. mannitol) will acutely raise circulating blood volume (via both the direct bolus of fluid and the osmotic effects of increased plasma osmolality). Patients with CHF may be unable to compensate for this increase in circulating blood volume, potentially leading to pulmonary edema and heart failure. Moreover, CHF is a risk factor for mannitol-induced renal failure [2]. These risks may be reduced by limiting other fluid administration, using a more concentrated version of hyperosmotic solution (i.e., 23.4% hypertonic saline), or adding a loop diuretic such as furosemide. Patients with CHF may already be hyperventilatory, which will limit the effectiveness of that intervention, and care must be taken to maintain hemodynamic stability when implementing sedation or tight blood pressure control. Good head positioning and treatment of seizures or fever remain appropriate interventions.


  1. Francisco de Assis Aquino Gondim, Venkatesh Aiyagari, Angela Shackleford, Michael N. Diringer (2005) Osmolality not predictive of mannitol-induced acute renal insufficiency. Journal of Neurosurgery 103 (3):444-447. doi:10.3171/jns.2005.103.3.0444 PubMed Link