Consultation with the specialist
Increased Intracranial Pressure
Ira Bergman MD1
1 Division of Child Neurology, The University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA.
Increased intracranial pressure (ICP) is both a symptom of serious intracranial pathology and a cause of irreversible neurologic injury. The following case history highlights the importance of prompt diagnosis and treatment of increased ICP.
Case History
An 18-month-old white male developed fever and lethargy. On physical examination he had nuchal rigidity and was lethargic but could be fully aroused. His cerebrospinal fluid (CSF) contained 1279/mm3 white blood cells, of which 90% were polymorphonuclear cells; the CSF glucose level was 5 mg/dL and protein was 63 mg/dL. Gram stain revealed Gram-negative rods. The child was treated with ceftriaxone. Five hours later, he had four generalized seizures. Serum sodium was 114 mEq/L, and an infusion of 3% saline at 80 mL/h was begun. Immediately following the seizures, the child was comatose but withdrew to pain. Thirty minutes later, he developed decerebrate posturing bilaterally and irregular respirations and had a dilated unreactive left pupil. He was given mannitol, pancuronium, and pentobarbital and was intubated and hyperventilated. Almost immediately the pupils became 3 mm in size bilaterally and equally reactive. A computed tomographic (CT) scan was obtained (Figure 1A). Twenty-four hours later, the child opened his eyes to mild stimulation and responded specifically to localized pain. The cerebral CT scan was repeated (Figure 1B).
