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Raised ICP. Joseph Frantzias, Haroon Rehman and Shami Acharya for NANSIG. JT, 49 year old lady, day 1 post-op cranotomy and resection of a right parietal meningioma. You are the FY2 on the neurosurgical ward. The HDU nurse calls you to see the patient as ‘she is very sleepy’.

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raised icp

Raised ICP

Joseph Frantzias, HaroonRehman and ShamiAcharya for

NANSIG

slide2

JT, 49 year old lady, day 1 post-op cranotomy and resection of a right parietal meningioma.

You are the FY2 on the neurosurgical ward. The HDU nurse calls you to see the patient as ‘she is very sleepy’.

How do you assess the patient?

on examination
On examination…
  • Opens eyes to voice, incomprehensible sounds, withdraws to pain on the right
    • On the chart: GCS15 one hour before.
  • Left upper and lower limbs paralysed (new)
  • BP150/100, HR 55, RR 18. Temp 36.7.
  • How do you proceed?
the intracranial compartment
The intracranial compartment
  • Intracranial components:
    • Brain and interstitial fluid 80%
    • Blood 10%
    • CSF 10%
  • Monro-Kelly principle: The cranium is a fixed cavity. Therefore an increase in the volume of one of the intracranial constituents should be accompanied by a decrease in the volume of another.
15 minutes after ct
15 minutes after CT…
  • Patient not opening eyes, incomprehensible sounds, extending on the right, no movement on the left.
  • BP 215/160, HR 30, RR 15 irregular
herniation syndromes
Herniation syndromes
  • Cingulate herniation:
    • Supratentorial mass
    • Cingulate gyrus under falx
    • Asymptomatic. ACA may be compromised
  • Uncal herniation:
    • Middle cranial fossa lesions
    • Uncusagainst tentorial edge
    • Impaired consciousness, ipsilateral dilated pupil, contralateral hemiplegia
  • Tonsillar herniation
    • Posterior cranial fossa lesions / LP
    • Cerebellar tonsil through foramen magnum
    • Impaired consciousness, high blood pressure, Cheyne-Stokes breathing, neck stiffness
slide10

Neurosurgical registrar on his way from the paediatric unit, but will be about 1 hour late due to traffic…

management
Management
  • ABC
    • Airway likely to be compromised if GCS<8.
  • Mannitol
    • Osmotic effect, decreases CSF production, increases cerebral blood flow and oxygen consumption, decreases blood viscosity
    • 0.25g/Kg at 4 to 6-hour intervals
    • Effective for 48-72 hours only
  • Hypertonic saline: as good as mannitol?
  • Loop diuretics: synergistic effect with mannitol
  • Hyperventilation
    • Decreased CO2 ➔ cerebral vasoconstriciton ➔ decreased blood volume ➔ decreased ICP
    • Too much may compromise brain perfusion
  • Steroids: for vasogenicoedema (tumours)
  • Ventricular drainage, barbiturate coma