Before the induction of anesthesia, it is essential to evaluate the patient’s neurological and systemic status thoroughly. A detailed understanding of the underlying cause of increased ICP (e.g., traumatic brain injury, intracranial hemorrhage, brain tumors) is necessary, as the anesthetic plan may need to be adjusted based on the etiology. Additionally, preoperative optimization should focus on addressing factors that could aggravate ICP, such as hypercapnia, hypoxemia, and hypertension.
Preoperative imaging
Updated brain imaging (CT or MRI) should be reviewed to assess the extent of mass effect, midline shift, or signs of impending herniation. This will help guide the urgency of surgical intervention and the anticipated difficulties during anesthesia induction and maintenance.
Neurological status
The patient’s baseline neurological function, including Glasgow Coma Scale (GCS) score, pupillary responses, and motor function, should be documented. Sudden changes in neurological status may indicate acute ICP elevation and necessitate immediate intervention.
Airway assessment
Many patients with elevated ICP, especially those with traumatic brain injury, may present with a reduced level of consciousness or altered airway reflexes, increasing the risk of aspiration. A rapid sequence induction (RSI) should be considered for patients at high risk of aspiration to minimize the duration of apnea and reduce the likelihood of hypoxemia during intubation.