Intracranial pressure (ICP) is the pressure that exists within the cranium, including its compartments (e.g., the subarachnoid space and the ventricles). ICP varies as the position of the head changes relative to the body and is periodically influenced by normal physiological factors (e.g., cardiac contractions). Adults in the supine position typically have a physiological ICP of ≤ 15 mm Hg; an ICP of ≥ 20 mm Hg indicates pathological intracranial hypertension. ICP may be elevated in a variety of conditions (e.g., intracranial tumors) and can result in a decrease in cerebral perfusion pressure (CPP) and/or herniation of cerebral structures. Symptoms of elevated ICP are generally nonspecific (e.g., impaired consciousness, headache, vomiting); however, more specific symptoms may be present depending on the affected structures (e.g., Cushing triad if the brainstem is compressed). Findings from brain imaging (e.g., a midline shift) and physical examination (e.g., papilledema) can indicate ICP elevation but may not be able to rule it out. Therefore, ICP monitoring and quantification are vital in at-risk patients. Management usually involves expedited surgery of resectable or drainable lesions, conservative measures (e.g., positioning, sedation, analgesia, and antipyretics), and medical therapy (e.g., hyperosmolar therapy such as mannitol or hypertonic saline, or glucocorticoids). Treatment options for refractory intracranial hypertension include temporary controlled hyperventilation, CSF drainage, and decompressive craniectomy (DC), as well as other advanced medical therapies (e.g., barbiturate coma, therapeutic hypothermia).

Skull fractures most typically occur as a result of blunt force trauma from contact sports, motor vehicle collisions, or falls. They are classified by anatomical location as either cranial vault fractures or basilar skull fractures. Cranial vault fractures involve one or more of the cranial vault bones, may be either open fractures or closed fractures, and are classified as linear skull fractures or depressed skull fractures. Basilar skull fractures involve one or more of the skull base bones and are classified as anterior, middle, or posterior cranial fossa fractures. Clinical features vary depending on bone involvement but may include lacerations, contusions, and hematoma of the scalp; palpable deformities; mobile bone fragments; liquorrhea; Battle sign; raccoon eyes; and signs of traumatic brain injury. Initial management of skull fractures focuses on identifying and addressing life-threatening injuries. Complications of skull fractures include CSF leaks (which increase the risk for meningitis), cranial nerve disorders (due to compression or transection), and epidural hematomas. Expectant management may be sufficient for simple fractures but neurosurgery may be necessary for unstable fractures and fractures with associated complications. Open head injuries can occur when skull fractures are associated with rupture of the dura mater, which can increase the risk of CNS infection.

Pituitary adenomas (also known as pituitary neuroendocrine tumors) are benign tumors that arise sporadically from the anterior pituitary gland. They are classified as either microadenomas or macroadenomas according to their size, and as either secretory (functional) or nonsecretory (nonfunctioning) according to their ability to secrete hormones. Secretory adenomas produce the pituitary hormone of the cell type from which they arise, which results in a state of hyperpituitarism. Nonsecretory macroadenomas can destroy the surrounding normal pituitary tissue, which results in hypopituitarism. Additionally, large macroadenomas compress the optic chiasm; therefore, patients may present with signs of mass effect such as bitemporal hemianopsia. MRI sella with IV contrast is the gold standard imaging method for the pituitary and should reveal any intrasellar masses. Pituitary hormone assays are used to evaluate patients for endocrine abnormalities, and perimetry is used to identify visual field defects. Transsphenoidal hypophysectomy is the first-line therapy for most patients with symptomatic pituitary adenomas; patients with nonsecretory microadenomas generally only require follow-up (until they become symptomatic), and prolactin-producing pituitary adenomas (prolactinomas) should be initially treated with dopamine agonists (e.g., cabergoline, bromocriptine). Pituitary irradiation is indicated in recurrent pituitary adenomas and/or if surgical therapy is contraindicated.