Question 29

You are called to review a 55-year-old female following difficult prolonged surgery for emergency clipping of a ruptured left middle cerebral artery (MCA) aneurysm. She had returned to the ICU three hours earlier, intubated, ventilated and with an external ventricular drain (EVD) in situ.

She has developed frank blood in the EVD, and her ICP has increased to 57 cmH2O. Outline your approach to her initial management.

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College answer

Not available.


This question is almost identical to Question 6  from the second paper of 2015, except this time some of the punctuation has been revised and some of the words rearranged. Also, this time, the patient is not hypertensive. The last time this question appeared, the college examiners had commented that "some candidates failed to recognise this as an emergency situation". Thus:

Introductory statement

  • This is a super-urgent emergency critical situation of some importance.


  • Organise CT
  • Inform theatres
  • Inform neurosurgery
  • Start organising equipment for urgent patient transport to OT via CT

Specific management

  • Urgent CT angiogram
  • Definitive surgical control

Endpoints of therapy

  • SBP 150-170
  • ICP <20
  • SpO2 > 95%
  • CO2 35 mmHg

ICP management:

  • Position the head (45 °head up, facing straight)
  • Loosen the ETT ties
  • Remove the C-spine collar
  • Decrease PEEP as much as possible
  • Increase sedation
    • Propofol sedation to decrease distress and thus decrease ICP
    • Benzodiazepines may be of use (but they do not decrease the CMRO2 as much as propofol)
  • Drain some CSF from the EVD
  • Paralysis with neuromuscular junction blocker
  • Osmotherapy
    • Mannitol 20%
    • Hypertonic saline
  • Controversial measures
    • Barbiturate coma if other methods of lowering ICP have failed
    • Decompressive craniectomy