title: Neurointensive care management of raised intracranial pressure caused by severe valproic acid intoxication.
abstract: BACKGROUND
  We describe the neurointensive care (NIC) management of a patient with severe cerebral swelling and raised intracranial pressure (ICP) after severe sodium valproic acid (VPA) intoxication. A previously healthy 25-year old male with mild tonic-clonic epilepsy was found unconscious with serum VPA levels >10,000 micromol/l. The patient deteriorated to Glasgow Motor Scale score (GMS) 2 and a CT scan showed signs of raised ICP. Early ICP was elevated, >50 mm Hg, and continuous EEG monitoring showed isoelectric readings.
  
  
  METHODS
  The patient was treated with an ICP-guided protocol including mild hyperventilation, normovolemia, head elevation and intermittent doses of mannitol. Due to refractory elevations of ICP, high-dose pentobarbital infusion was initiated, and ICP gradually normalised.
  
  
  RESULTS
  There were several systemic complications including coagulopathy, hypocalcemia and pancreatitis. The patient remained in a depressed level of consciousness for 2 months but gradually recovered, showing a good recovery with minor subjective cognitive deficits by 6 months.
  
  
  CONCLUSIONS
  We conclude that NIC may be an important treatment option in cases of severe intoxication causing cerebral swelling.
authors.affiliation: Department of Neuroscience, Uppsala University Hospital, Uppsala, 75185 Sweden. Niklas.Marklund@neurokir.uu.se
authors.forename: Niklas
authors.initials: N
authors.lastname: Marklund
authors.forename: Per
authors.initials: P
authors.lastname: Enblad
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Ronne-Engström
mesh_terms: D000328:Adult; D000927:Anticonvulsants / Q000506:poisoning*; D001929:Brain Edema / Q000139:chemically induced / Q000000981:diagnostic imaging / Q000628:therapy; D003422:Critical Care / Q000379:methods*; D004830:Epilepsy, Tonic-Clonic / Q000188:drug therapy*; D006801:Humans; D019586:Intracranial Hypertension / Q000139:chemically induced* / Q000000981:diagnostic imaging / Q000628:therapy*; D008297:Male; D008991:Monitoring, Physiologic; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D014635:Valproic Acid / Q000506:poisoning*
chemical_list: D000927:Anticonvulsants; D014635:Valproic Acid