Which of the following is an early sign of increased intracranial pressure in a head-injured patient?

• A. Altered level of consciousness
• B. Dilated pupils
• C. Seizures
• D. Hypotension

Answer: (A)

Early changes in intracranial pressure show up first as a change in brain function, particularly in the level of consciousness. As ICP rises, cerebral perfusion pressure (CPP = MAP − ICP) falls, compromising blood flow to the brain's arousal centers. Even a small drop in CPP can blunt the reticular activating system, leading to restlessness, confusion, drowsiness, or a decreased responsiveness—the earliest warning that the brain is not being adequately perfused.

Pupil changes, seizures, and dramatic blood pressure shifts tend to occur later or under special circumstances. Dilated or unequal pupils may indicate herniation or cranial nerve involvement rather than being an initial sign of increased ICP. Seizures can happen with brain injury but are not reliably the first indicator. Hypotension is not an early sign of rising ICP and, in fact, worsens brain perfusion when it occurs.