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Increased Intracranial Pressure

This document discusses increased intracranial pressure (ICP) and its management. It covers the Monro-Kellie doctrine, ways ICP can increase both physiologically and pathologically, consequences of elevated ICP like reduced cerebral blood flow and herniation, methods for monitoring and lowering ICP like external ventricular drainage and osmotherapy with mannitol. The goal of management is to keep ICP below 20 mmHg through surgical evacuation, drainage, medications and other techniques.

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124 views38 pages

Increased Intracranial Pressure

This document discusses increased intracranial pressure (ICP) and its management. It covers the Monro-Kellie doctrine, ways ICP can increase both physiologically and pathologically, consequences of elevated ICP like reduced cerebral blood flow and herniation, methods for monitoring and lowering ICP like external ventricular drainage and osmotherapy with mannitol. The goal of management is to keep ICP below 20 mmHg through surgical evacuation, drainage, medications and other techniques.

Uploaded by

roshanleung11
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Increased Intracranial Pressure

Concept of Intracranial Pressure


Monro-Kellie Doctrine
Total craniospinal volume=Blood + CSF + parenchyma
How to increase the ICP ?

 Physiological condition
 Pathological condition
Physiological condition
 Valsaver maneuver

Decrease venous return

 Hypercapnia induced

Vessel dilation result


Increase blood volume
Pathological conditions
 Haemorrhage cause haematoma
 Venous congestion
 Brain tumour
 Hydrocephalus
 Craniosynostosis
 Massive depressed #
 Oedema
Can be multiple factors
Tumour + obstructive hydrocephalus

Head injury haematoma + brain swelling


Consequence of raised ICP
Consequences of increase ICP
Reduce CBF

Herniation
Pressure Volume Curve
Arterial, Venous & CSF
Key Issue : CBF
Regulation of CBF

 Flow-metabolic coupling

 Pressure autoregulation

 Chemoregulation
Flow-metabolic coupling
Chemoregulation
Pressure autoregulation
Does CPP always tell us the true CBF ?
No
Impaired
PRESSURE AUTOREGULATION
in HI
Can CBF be directly measure ?
 Xenon CT
 Contrast CT (perfusion study)
 Positron Emission Tomography (PET)
 SPECT
Cannot provide continue
monitoring
ICP monitoring
S&S suggest increase ICP
 Headache
 N&V
 Blurring of vision
 Reduce conscious level
 Cushing reflex
 Focal problem to location of the mass lesion and
hesitation
Papilloedema
Cushing reflex
 Widening pulse pressure
 irregular breathing
 reduction of the heart rate

 1st stage, hypertension and tachycardia try to


increase the CBF
 2nd stage, bradycardia because stimulate the
vagus nerve trigger parasympathetic response
 3nd, futher increase ICP affect brain stem
induce irregular respiratory breathing.
External ventricular drainage (EVD)
 Good accuracy
 Cost: HK$1000
 Drainage:Yes
 Infection: High
 Technique: Demanding
ICP Management target for adult
ICP < 20mmHg
General Management
 Position head up 30 。
 Treat cough
 Treat fever
 Normal ventilation ( pCO2 35-45mmHg )
 Normal BP ( MAP 50-150mmHg )
 Hb > 10g/dL
 Avoid overhydration
 Sedation
Specific Management
 Surgical evacuation
 EVD
 Osmotherapy: Mannitol, Hypertonic saline
 Craniectomy and Dural augmentation
 Hyperventilation
 Barbiturates therapy ( reduce brain metabolism)
but also BP
EVD
Continuous monitoring and intermittent drainage

Alarm set <20mmHg


Drain duration : 5 mins
Level : 15 cm H2O
Frequency : more frequent, more severe increase
of the ICP > 4×/hour, suggesting not effective
Continuous drainage

 Set a level for CSF to "overflow" , e.g. 20 cm


H2O height
 Drained CSF volume : higher output, more
severe
 For hydrocephalus only
 Not suitable for high ICP due to brain
swelling
Issues in ICP monitoring
Is the value valid ?

 Waveform ?
 Reference point ( transducer level )
 Regular " zeroing"
Why drainage not effective ?

 Collapsed ventricle
 Complete / partial blocked catheter
Mannitol

 The diuretic which able to cross BBB


 0.5 - 1 gm/ Kg, rapid infusion, regular or
p.r.n.
 Not effective for prolong use
Hyperventilation
Reduce PCO2 course vessel constriction which
increase the CVR and reduce the cerebral blood
volume and reduce the ICP.

MAY DECREASE CBF AS WELL


Take Home Message
 Monro-Kellie Doctrine.
 Valsaver Maneuver use to check the ICP valuefor
the patient using ventilator.
 Pressure volume curve, critical volume.
 Increase ICP, reduce CBF.
 Regulation of CBF affected by metabolic rate,
pressure, chemical.
 Cushing reflex.
 ICP target value ＜ 20mmHg
 EVD intermittent / continuous drainage

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