INCREASED INTRACRANIAL PRESSURE
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1 INCREASED INTRACRANIAL PRESSURE Sheba Medical Center, Acute Medicine Department Irene Frantzis P-Year student SGUL 2013
2 Normal Values Normal intracranial volume: 1700 ml Volume of brain: ml CSF: ml Normal ICP: Adults:<10-15 mmhg Children: <3-7 mmhg
3 Definition Persistant elevation of > 20mmHg for more than 10 minutes = elevated ICP If pressure is > 30 mmhg, there is a poor prognosis
4 Causes Mass lesions Tumor, Hematoma, Abscess CSF disturbance Hydrocephalus Obstruction of venous sinuses Depressed fractures, cerebral venous thrombosis Diffuse brain edema/swelling Encephalitis, Meningitis, Reye s Syndrome, Subarachnoid hemorrhage, Lead encephalopathy, water intoxication, neardrowning Idiopathic
5 Cerebral Edema Vasogenic cerebral edema- most common form Cytotoxic cerebral edema- secondary to cellular injury Ex. Ischemia, metabolic poisons Hydrocephalic edema
6 Signs and Symptoms Headache: worse in the morning/ when arising Band-like, pressure Exacerbated by sneezing, coughing, exertion Vomiting Projectile Often in the morning Papilloedema Indicates chronic elevated ICP Decreased consciousness Cognitive change
7 Signs and Symptoms Cognitive Change Most likely due to caudal displacement of diencephalon and midbrain Light- near pupillary dissociation Cushing s Triad (usually late signs) Systolic hypertension Bradycardia Respiratory depression
8 Diagnosis Clinical signs + Radiology+ Laboratory results Radiology- CT is quick and easy Good for detecting edema, tumor, compressed cisternae, midline shift Lab: Look for hyponatremia, check Arterial Blood Gases for increase pco2
9 Radiology 45 year old pt with acute intracranial hemorrhage, cerebral edema and midline shift rq.gov/case.aspx?casei D=174
10 Monitoring ICP Can use techniques such as Intraventricular fluid filled catheter transducer system (but needs ventriculostomy) Catheter tip transducer systems Can use lateral ventricles (usually) In infants- transduction device over anterior fontanelle Indications to monitor ICP are usually in trauma situations Patients with severe head injury Abnormal CT scan
11 Treatment Depends on cause General: Elevate head degrees-> helps to lower JVP (normally the principle determinant of ICP), also lower venous outflow Keep pco2 < 32 mmhg, but > 25 mmhg Restrict fluids Furosemide 1mg/kg single dose
12 Treatment cont d Mannitol: 1g/kg- effect lasts for 3-6 hrs 0.25 g/kg every 4-6 hrs Adverse effects: CHF, hypokalemia, hyperosmolarity, sudden rebound ICP Dexamethasone mg initially, then 4mg every 6 hrs For edema Analgesia and Sedation IV propofol, etomidate, midazolam for sedation Morphine, alfentanil for analgesia
13 Treatment Decompressive craniectomy Beneficial in trauma, cerebral infarction, intracerebral, subarachnoid hemorrhage, Reye s syndrome Decreased mortality, but may increase morbidity CSF drainage Ventriculostomy- risk of infection, hemorrhage Avoid pyrexia Can increase ICP Seizures should be managed aggressively Can precipitate rapid deterioration
14 Treatment cont d Neuromuscular blockade When analgesia and sedation do not reduce muscle activity which raises ICP Hypothermia Second-tier treatment Investigated in head injury as means of controlling ICP Barbiturate coma Not common practice Depresses cerebral metabolic activity lower cerebral blood flow lower ICP
15 Effects of Space- Occupying Lesions Increase volume in intracranial space minimal inc in pressure due to compliance when CSF is displaced, blood is displaced and compliance is lost increase ICP
16 Effects of SOL Cerebellar Tonsil herniation Through foramen magnum Compress medullary respiratory centers Leads to death Lateral displacement of brain Change in consciousness
17 Brain Herniation Uncal Central.1.2 Cingulate.3 Transcalvarial.4 Upward cerebellar Tonsilar.6.5 Image taken from wikipedia
18 Effects of SOL Uncal herniation (usually ipsilateral) May push midbrain on controlateral tentorium compression of cerebral peduncle ipsilateral hemiparesis Compress CN III: ipsilateral pupil dilatation Compress midbrain cerebral peduncle: hemiparesis hemiplegia Compress posterior cerebral artery:may hemorrhage to occipital lobe homonymous hemianopsia Brainstem compression respiratory, postural oculomotor change
19 Effects of SOL- increased ICP Central Herniation (Rostrocaudal deterioration) Change in consciousness Respiratory changes Diencephalon Cheyne- Stokes respiration (hyperventilation and apnea) Midbrain central neurogenic hyperventilation Pons Apneustic respiration (prolonged inspiratory phase, apnea) Medulla ataxic respiration (irregular, chaotic, apnea)
20 Uncal Herniation
21 Effects of SOL- increased ICP Central herniation Pupillary changes Small, reactive: compressed diencephalon dec sympathetic Dilated, fixed: compressed CN III Midposition, fixed: compress both CN III, midbrain Changes in postural reflexes Decorticate rigidity: Flexed arms, extended legs Decerebrate rigidity: arms and legs extended
22 Posture Change
23 References Dunn LT, Raised Intracranial Pressure J Neurol Neurosurg Psychiatry 2002; 73: Irwin R.S., Rippe JM. Manual of Intensive Care Medicine, 4th ed. Lippincott william and Wilkins p
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