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RAISED ICP. Atandrila Das. Monro-Kellie Doctrine. Cranial cavity is a rigid sphere Filled to capacity with non compressible contents Increase in the volume of one of the constituents will lead to a rise in pressure. Intracranial pressure-volume relationship. Cerebral blood flow.

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raised icp

RAISED ICP

Atandrila Das

monro kellie doctrine
Monro-Kellie Doctrine
  • Cranial cavity is a rigid sphere
  • Filled to capacity with non compressible contents
  • Increase in the volume of one of the constituents will lead to a rise in pressure
cerebral blood flow
Cerebral blood flow
  • CBF = (CAP – JVP) / CVR
  • CBF is normally maintained at a relatively constant level by autoregulation of CVR over a wide range of BP
  • In the setting of raised ICP, CBF can be reduced
  • CPP is a clinical surrogate for the adequacy of cerebral perfusion.
  • CPP = MAP – ICP
  • CPP becomes dependent on MAP when autoregulation compromised
  • To maintain CPP in the setting of raised ICP, systemic BP needs to be elevated.
contents
Contents
  • Brain – 80%
  • Blood – 10%
  • CSF – 10%
causes of raised icp
Causes of raised ICP
  • Increased volume of normal contents
    • Brain: oedema, benign intracranial HTN
    • CSF: hydrocephalus
    • Blood: vasodilatation, venous thrombosis
  • Space occupying lesions
    • Tumour
    • Abscess
    • Intracranial heamorrhage
symptoms signs
Symptoms/signs
  • DROWSINESS
  • Headache
  • Nausea/vomiting
  • Papilloedema
  • Cushing’s triad
cerebral herniation
Cerebral herniation
  • Can occur depending on cause of raised ICP
  • 3 major types:
    • Transtentotial
    • Foramen magnum
    • subfalcine
transtentorial
Transtentorial
  • Displacement of brain and herniation of uncus of temporal lobe through the tentorial hiatus
  • Causes compression of:
    • midbrain : contralateral hemiparesis (usually), Cushing response, , respiratory failure (cheyne-stokes)
    • CN III: dilatation of ipsilateral pupil initially
    • Posterior cerebral artery: hemianopia
foramen magnum coning
Foramen magnum (coning)
  • Progressively increasing ICP causes further downward herniation of the brainstem into foramen magnum or coning.
  • This results in shearing of the perforators supplying the brainstem and haemorrhage within (Duret heamorrhage).
  • Traction damage to pituitary stalk resulting in DI.
  • With progressive herniation pupils change from dilated and fixed to midsize and unreactive.
  • Signifying irreversible events leading to brainstem death.
subfalcine
Subfalcine
  • Cingulate gyrus herniates under falx.
  • Usually asymptomatic unless ACA kinks and occludes causing bifrontal infarction.
icp monitoring
ICP monitoring
  • Indications:
    • Head injury
    • Following major intracranial surgery
    • Assessment of benign intracranial HTN
  • Normal ICP: 10-15mmHg
  • Can be recorded from ventricle, brain substance, subdural or extradural space
  • Risks: CNS infection and intracranial haemorrhage
management
Management
  • Definitive treatment: treat underlying patholgy
  • To control raised ICP:
    • Head elevation
    • Controlled ventilation: maintain PaCO2 at 30-35 mmHg. Reduction of CO2 will reduce cerebral vasodilatation
    • Sedation/paralysis: decrease metabolic demand
    • If ventricular catheter in situ, drain CSF
    • Diuretic therapy: mannitol – osmotic diuretic, increases serum osm and draws water out of the brain. Usual dose: 0.5-1.0g/kg. monitor serum osm
    • Hypertonic saline
    • Barbiturate therapy: thiopentone when given as a bolus dose can be helpful in temporarily reducing ICP.
bibliography
Bibliography
  • Essential Neurosurgery. Prof. A Kaye. Third edition
  • Handbook of neurosurgery. M. Greenberg. Sixth edition
  • Uptodate: Evaluation and management of elevated intracranial pressure in adults. E.Smith
  • http://www.millerneurosurgery.com/index.php/procedures