2025 – PAGE 399 – NEUROLOGY

INCREASED INTRACRANIAL PRESSURE AND HEADACHES

INCREASED INTRACRANIAL PRESSURE (ICP)

Signs of increased intracranial pressure (ICP) include splitting sutures, bulging fontanelle, regression of milestones, setting-sun sign, horizontal diplopia, papilledema, nausea, vomiting, anorexia, FTT, systemic hypertension, tachypnea/hyperventilation (or irregular respirations), and bradycardia on exam. Pupils may be dilated and not reactive (this can be unilateral or bilateral). Treatment may include mannitol, furosemide, hyperventilation, a VP shunt, or treat the cause!

PEARL: If the patient has other symptoms consistent with increased ICP but no papilledema, it’s probably still increased ICP! Papilledema is a LATE finding. Also, some of the classic symptoms of increased ICP were described by Cushing. Cushing’s triad includes increased systolic blood pressure with a wide pulse pressure, bradycardia, and abnormal respirations (irregular or tachypneic). ALWAYS circle the respiratory rate because it might be the only clue for conditions like increased ICP and acid-base disorders!

MNEMONICS: Increased ICP is also known as Intracranial Hypertension. The systemic increase in blood pressure is the body’s way of trying to match the brain’s BP.

IMAGE: (Papilledema) www.pbrlinks.com/ICP1
IMAGE: (Sun Setting Sign) www.pbrlinks.com/ICP2

LUMBAR PUNCTURE

Go ahead and order a lumbar puncture for anyone in whom you suspect meningitis UNLESS they have a focal neurologic deficit. Lumbar punctures are contraindicated if a brain tumor/mass is suspected.

DANDY WALKER MALFORMATION

Dandy Walker malformation can present with delayed motor development, progressive enlargement of the skull, breathing problems, and signs of increased intracranial pressure (nausea, vomiting, seizures). It’s a Posterior Fossa abnormality that involves the cerebellum and the fluid spaces around it. The cerebellar vermis is either partially or completely missing (that’s the part usually between the 2 cerebellums). There is increased fluid in the fourth ventricle. It’s associated with PHACES and Congenital Melanocytic Nevi.

• (DOUBLE TAKE) PHACES SYNDROME: Diagnosis requires a large hemangioma in the face/neck area PLUS one of the following defects.
  • Post Fossa malformation (DANDY WALKER)
  • Hemangioma. Often in the distribution of the Facial Nerve. Look for a large segmental hemangioma on the FACE. Segmental refers to what looks like a nerve distribution (segmented by normal skin in between).
  • Arterial cerebrovascular anomaly: Including STROKES
  • Cardiac anomalies: Especially COARCTATION OF THE AORTA
  • Eye anomalies: MICROPHTHALMIA, STRABISMUS
  • Sternal defect
  • IMAGE: www.pbrlinks.com/PHACES1
• MNEMONIC: After the exam, you might feel like taking a DANDY little WALK all over the PHACES of ABP question contributors! Yes, that includes me. Also, Posterior Fossa = PF = which could kind of be used to spell PFaces.