Signs of increased intracranial pressure

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Obtain noncontrast head CT (Class II) or rapid-sequence MRI (Class II)

Yes

Workup

Imaging, either noncontrast head CT or rapid-sequence brain MRI, is required for definitive diagnosis of a space-occupying brain lesion. Once seen on imaging, additional laboratory tests should be acquired in anticipation of a malignant lesion. These should include CBC (to assess the patient’s absolute neutrophil count and hemoglobin level), chemistries (to assess for signs of tumor lysis syndrome such as elevated potassium and phosphorus levels and low calcium), uric acid, lactate dehydrogenase, coagulation laboratory studies, and blood cultures. Involving the neurosurgery team early is imperative.

Initial Treatments

In the ED, initial treatment for a newly discovered space-occupying brain lesion consists of stabilization and resuscitation. If the patient has significantly altered mentation and is unable to protect the airway, consider intubation. Also, elevate the head of the bed to 30° to help decrease ICP while maintaining cerebral perfusion pressure, and keep the patient’s head midline to facilitate jugular vein drainage. Neurosurgical consultation will help guide next steps (eg, corticosteroid use for tumor-related brain edema, surgical intervention). Perform frequent neurologic checks and be vigilant for signs of impending brain herniation, including irregular respirations, bradycardia, and hypertension (Cushing triad). Treatment with hyperosmolar agents, mannitol, or hypertonic saline, may be needed to help decrease ICP.