Presentation and Management of Raised Intracranial Pressure Amro

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

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

Pressure-Volume n Increase in volume in one compartment leads to change in volume in the other ones. n n 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 A. B. C. D. E. Cingulate herniation Uncal herniation Central herniation Outside herniation Tonsillar herniation

ICP waveform

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

n Cerebral autoregulation n Ability of cerebral vessels to maintain cerebral perfusion within strictly determined limits n n n 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 n If ICP goes up, how does the brain get perfusion? n n n Process of autoregulation CPP = MAP - ICP If: n n n MAP=85 mm. Hg ICP=15 mm. Hg CPP ?

n CPP 50 -140 mm. Hg

n 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 n n VITAMEN D Other:

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

GCS Decreased Level of Consciousness

n Neurological: n n n Pupillary dilation Hemiplegia Cranial nerve deficit

missinglink. ucsf. edu/. . . / Herniation. Gross. jpg

missinglink. ucsf. edu/. . . / Tentorial. Notch. Blum. jpg

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

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

False localization n Kernohan’s notch

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

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

Investigations n n URGENT CT head NO Lumbar Puncture

What is the treatment of high ICP? n General measures: n n n n Head elevation (30 degrees) No neck compression Mannitol for patients who have decreased LOC (or Furosemide) Steroids (Dexamethazone) for tumors Hyperventilation: controlled to PCO 2 35 -40 mm. Hg Sedation, muscle relaxants Hypothermia Barbiturates: terminal option

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

Vascular - SAH / ICH www. musc. edu/. . . /Fall 2003/ Theodosha/brain 31. gif www. learningradiology. com/ archives 2007/COW%20. . radiology. rsna. org/ content/244/3/923/F 1. large. jpg

Infection - Abscess

Trauma n Localized Epidural Hematoma Subdural Hematoma

Trauma n Diffuse www. learningradiology. com/. . . /cow 315 -1 arr. jpg

Tumor Meningioma Glioblastoma Multiformi

Hydrocephalus

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