Cerebral Compression: Emergency Recognition, Stepwise Management, and Prognosis

Recognition (Classic Signs)

• Sudden severe headache ("worst of life")
• Altered consciousness (confusion → coma)
• Seizures
• Nausea/vomiting (projectile)
• Focal deficits: hemiparesis, cranial nerve palsies (CN III dilation)
• Vital sign changes: hypertension, bradycardia, irregular respirations (Cushing's triad)
• Pupillary asymmetry (uncal herniation)

Immediate Management (ABCs)

1. Call EMS / Activate neurosurgical team.
2. Airway: Intubate if GCS ≤8 or declining.
3. Breathing: Ventilate to normocapnia (PaCO₂ 35–40 mmHg); avoid hyperventilation unless herniation imminent.
4. Circulation: Maintain CPP (MAP > ICP); avoid hypotension.
5. Head elevation 30° (if no spinal injury) to promote venous drainage.

Definitive Treatment

• Imaging: Non-contrast head CT (rapid); MRI if subacute.
• Medical: Mannitol 0.5–1 g/kg or hypertonic saline; dexamethasone for vasogenic edema (tumor).
• Surgical: Hemicraniectomy, hematoma evacuation, tumor resection, EVD for hydrocephalus.
• ICP Monitoring: Intraparenchymal bolt or EVD for continuous monitoring.

Prognosis

Time to decompression is critical. Outcomes range from full recovery to severe disability or death depending on etiology, duration of compression, and age.