Presentation and Management of Raised Intracranial Pressure

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Presentation transcript:

Presentation and Management of Raised Intracranial Pressure Amro Al-Habib MD, FRCSC, MPH Neurosurgery

Basics Components of cranium Brain 1400 ml CSF 75-100 ml Blood 75ml Monro-Kellie Doctrine These contents are incompressible Therefore, change in volume of the brain is associated with change in CSF or blood volume

Pressure-Volume Increase in volume in one compartment leads to change in volume in the other ones. E.g. brain tumor ---> CSF volume then blood volume  For how long could this go on?

Raised ICP Laurence T Dunn, J neurol Neurosurg Psychiatry, 2002

Can somebody walk around with a raised ICP?

Raised ICP and brain shift Cingulate herniation Uncal herniation Central herniation Outside herniation Tonsillar herniation

ICP waveform

Normal ICP Raised ICP Laurence T Dunn, J neurol Neurosurg Psychiatry, 2002

Cerebral autoregulation Ability of cerebral vessels to maintain cerebral perfusion within strictly determined limits Rise in SBP ----> Constriction of cerebral arteries Low SBP ----> cerebral vessels dilate to accommodate Loss of autoreglation: Change in cerebral blood flow with the change in BP

Cerebral Autoregulation Raised ICP Laurence T Dunn, J neurol Neurosurg Psychiatry, 2002

BP and CBF If ICP goes up, how does the brain get perfusion? Process of autoregulation CPP = MAP - ICP If: MAP=85 mmHg ICP=15 mmHg CPP ?

CPP 50-140 mmHg

20 year old man. Had car accident (MVC) as unrestrained driver. He presented with BP 75/30, HR 125 bpm. Unconscious, with right hemiplegia. What is going on?

Possible Causes VITAMEN D Other:

Clinical Presentation of raised ICP Headache, vomiting, papilloedema Headache Early morning Throbbing / Bursting  sneezing, coughing Papilleodema Reliable but may take several days Associated fundal hge indicates acute and severe rise in ICP

Decreased Level of Consciousness GCS Decreased Level of Consciousness

Neurological: Pupillary dilation Hemiplegia Cranial nerve deficit

missinglink.ucsf.edu/.../ HerniationGross.jpg

missinglink.ucsf.edu/.../ TentorialNotchBlum.jpg

Trans-tentorial herniation: - Ipsilateral dilated pupil - Contra-lateral weakness

missinglink.ucsf.edu/.../ tonsillar%20hern-2a.jpg

False localization Kernohan’s notch

Raised BP (recall: CPP=MAP-ICP) Respiratory change: Systemic: Raised BP (recall: CPP=MAP-ICP) Respiratory change: Cheyne-Stokes breathing: Oscillating periods of apnea-tachypnea Respiratory centers compromise

Raised ICP in infants Widened sutures Increased Head circumference Dilated head veins “Sun set” eyes

Investigations URGENT CT head NO Lumbar Puncture

What is the treatment of high ICP? General measures: Head elevation (30 degrees) No neck compression Mannitol for patients who have decreased LOC (or Furosemide) Steroids (Dexamethazone) for tumors Hyperventilation: controlled to PCO2 35-40 mmHg Sedation, muscle relaxants Hypothermia Barbiturates: terminal option

What is the treatment of high ICP? Specific treatment: Depends on the cause VITAMEN D

Vascular - SAH / ICH www.learningradiology.com/ archives2007/COW%20.. www.musc.edu/.../Fall2003/ Theodosha/brain31.gif radiology.rsna.org/ content/244/3/923/F1.large.jpg

Infection - Abscess

Trauma Localized Epidural Hematoma Subdural Hematoma

Trauma Diffuse www.learningradiology.com/. ../cow315-1arr.jpg

Tumor Meningioma Glioblastoma Multiformi

Hydrocephalus

Can we monitor ICP? forum.interes.ge/index. php?showtopic=564&st=20