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Intracranial pressure (ICP) monitoring and CPP . PREPARED BY Fatima Hirzallah MISS. Intracranial pressure (ICP): . The main components inside the cranium are: - brain tissue (80%), blood (10%), and cerebrospinal fluid (CSF (10%).

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intracranial pressure icp monitoring and cpp

Intracranial pressure (ICP) monitoring and CPP


Fatima Hirzallah MISS

intracranial pressure icp
Intracranial pressure (ICP):

The main components inside the cranium are: - brain tissue (80%), blood (10%), and cerebrospinal fluid (CSF (10%).

So that any increase in the size of brain tissue or increase in the volume of the CSF or problem in the blood vessel (E.g. bleeding into the cranium) will cause increase in the ICP.

 The normal ICP in patients should be less than

15mm Hg.


The effect of increase in ICP will cause neurological deficit (sensory, motor, level of consciousness) or other problem such as seizure so that it is important in some patient to monitor ICP.

indications for icp monitoring
Indications for ICP monitoring

1- patients with severe head injury ( GCS≤ 8 after cardiopulmonary resuscitation).

A-  with abnormal admitting head CT.

B-   normal CT but with more or equal to 2 of the risk factor which include( age > 40, SBP< 90, decerebrate or decorticate posturing on motor exam unilateral or bilateral).

2-     Multiple system injured with altered level of consciousness

3-     Subsequent to removal of intracranial mass.

contraindications to use icp monitoring
Contraindications to use ICP monitoring

1-awake patient, we will follow neurological exam.

2-Coagulopathy( e.g. DIC ), if ICP monitoring is essential; consider taking steps to correct coagulopathy by using fresh frozen plasma and platelet and plan for subarachnoid bolt or epidural ( but intravantricular or intraparanchymal is contraindicated.

*Remove monitor when ICP become normal for 48-72 hours after withdrawal from ICP monitor

cerebrospinal fluid
Cerebrospinal Fluid
  • CSF, a clear and colorless fluid with a specific gravity of 1.007, is produced in the ventricles and is circulated around the brain and the spinal cord through the ventricular system. There are four ventricles: the right and left lateral and the third and fourth ventricles

Monitoring sites

1-Intraventricular space: -

*This approach is accomplished through placing a small catheter into the ventricular system (ventriculostomy).

*The catheter inserted through burr hole under local or general anesthesia into the anterior horn of the lateral ventricle, also the preferred side to insert the catheter is the nondominent hemisphere.


2-Subarachnoid space: -

ICP is accomplished through a placing a small hollow bolt or screw into the subarachnoid space.

It is inserted through burr hole, usually located in the front of the skull behind the hairline.

  3- Epidural (extradural) space: -
  • ICP monitoring is accomplished by placing a small fiberoptic sensor into the epidural space through local or general anesthesia.
  • Also the physician strips the dura from the inner table of the skull before inserting the sensor.
  4-Intraparenchymal: -
  • ICP is accomplished through placing a small fiberoptic catheter into parenchymal tissue.
  • *It is inserted after placing a subarachnoid bolt by punching the dura and the catheter is inserted 1 cm into the white matter of the brain.
Cerebral blood flow

The normal cerebral blood flow (CBF) is 50ml / 100g of brain tissue.

Although brain makes up to 2% of the body weight but it required 15% to 20 % of the resting cardiac output and 15% of the total body’s oxygen demands.


cerebral perfusion pressure
Cerebral perfusion pressure
  • The measuring of cerebral blood flow (CBF) is difficult but at bedside we can calculate the cerebral perfusion pressure (CPP).
  • *The cerebral perfusion pressure (CPP): is the blood pressure gradient across the brain and is calculated as the difference between the incoming mean arterial pressure (MAP) and the intracranial pressure (ICP).
  • CPP = MAP – ICP
Factors that affect the CBF: -

1- Acidosis (caused by hypoxia, hypercapnia, and ischemia), which result vasodilation by the effect of carbon dioxide, which lead to increase in CBF.

2- Alkalosis (caused by e.g. hypocapnia) which will result cerebral vasoconstriction, which lead to cerebral ischemia

3- Reduction in the metabolic rate (e.g. from hyporthermia or barbiturate).

4-Increase in the metabolic rate (e.g. hyperthermia).

  The normal CPP is 70 to 100 mmHg, and should be maintained within normal range to ensure adequate blood flow to the brain

  A sustained CPP 30 mmHg or less usually results in neuronal hypoxia irreversible neurologic damageand death.

  • When MAP equal to ICP; cerebral blood flow will cease.