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1、Presentation and Management of Raised Intracranial PressureAmro Al-Habib MD, FRCSC, MPHNeurosurgery1428 surgery teamDone by: 428 surgery teamObjectives:nTo learn what are the basics of ICP.nWhat things that form ICP inside the brain.nHow you lower ICP.nHow you can identify raised ICP.ICP: Intra-Cran
2、ial Pressure2428 surgery teamBasicsnComponents of craniumnNormal components:nBrain1400 mlnCSF75-100 mlnBlood75mlnAbnormal components:nTumorsnhematomanMonro-Kellie DoctrinenThese contents are incompressiblenTherefore, change in volume of the brain is associated with change in CSF or blood volume3428
3、surgery teamPressure-Volume nIncrease in volume in one compartment leads to change in volume in the other ones.nE.g. brain tumor - CSF volume then blood volume nFor how long could this go on? actually, it differs from one person to another, e.g. if a small benign brain tumor starts growing and then
4、reaches a phase of growing that the brain cant tolerate or accommodate “but some brains can”.4428 surgery teamv. impnAs much we increase the volume, the pressure will increase. nFirst, a little increase in pressure with a little increase in volume.nThen, with the same increase in volume there was a
5、huge increase in pressure. “an increase in the volume a little bit can take the curve over”nThis is the characteristics of brain within a few minutes everything can change.nPt. will came with headache and vomiting and within a small increase in the volume the pressure was not tolerated and he had to
6、 go to emergency craniotomy.Raised ICP Laurence T Dunn, J neurol Neurosurg Psychiatry, 20025428 surgery teamCan somebody walk around with a raised ICP? Yes,most pts. with brain tumors they came walking to the hospital6428 surgery teamRaised ICP and brain shiftA.Cingulate herniationB.Uncal herniation
7、C.Central herniationD.Outside herniationE.Tonsillar herniationHerniations in the brain: the brain is actually under so much pressure and it willgo to least resistance part in the brain.7428 surgery teamFrom the previous slidenUncal herniation: uncus is the most medial part of the temporal lobe so, i
8、ts the part that is going to herniate most common clinically seennCentral herniation: a hematoma or mass compressing the upper part, it pushes the whole brain down through the tentorial opening.nTonsillar herniation: if there is massive increase in the ICP especially that around the cerebellum, the
9、tonsil will come down to the foramen magnum and then it compresses the lower medulla where the centre of respiration is there and the pt will stop breathing. This type is fatal8ICP waveformIts the same as the heart waveform and it gives the brainpulsation and this pulsation is what forms your ICP.94
10、28 surgery teamNormal ICPRaised ICP Laurence T Dunn, J neurol Neurosurg Psychiatry, 200210428 surgery teamnCerebral autoregulationnAbility of cerebral vessels to maintain cerebral perfusion within strictly determined limitsnRise in SBP - Constriction of cerebral arteries nLow SBP - cerebral vessels
11、dilate to accommodatenLoss of autoreglation: Change in cerebral blood flow with the change in BP11428 surgery teamCerebral AutoregulationRaised ICP Laurence T Dunn, J neurol Neurosurg Psychiatry, 200212428 surgery teamBP and CBFnIf ICP goes up, how does the brain get perfusion?nProcess of autoregula
12、tionnCPP = MAP ICP “v. imp”nIf:nMAP=85 mmHgnICP=15 mmHgnCPP ?CPP: Cerebral Perfusion PressureMAP: Mean Arterial Pressure13428 surgery teamnCPP 50-140 mmHg14428 surgery teamn20 year old man. Had car accident (MVC) as unrestrained driver. He presented with BP 75/30, HR 125 bpm. Unconscious, with right
13、 hemiplegia.What is going on?Another possibility is the patient has hematoma in the brain thats why he is with hemiplegia and he is bleeding somewhere in the body and because of that he is hypotensive and unconscious and he has high HRHow we deal with him in the emergency ?ABC fluid C.T to know why
14、he is unconscious 15428 surgery teamPossible Causes nVITAMEN D is vitamin D deficiency is a possible cause of raised ICP? NO, it an abbreviation of Vascular, Infection, Trauma, Autoimmune, Metabolic, Endocrine, Neoplastic, Drugs.nOther:16428 surgery teamClinical Presentation of raised ICPnHeadache,
15、vomiting, papilloedema V.impnHeadachenEarly morningnThrobbing / Burstingn sneezing, coughingnPapilleodemanReliable but may take several days “happened only with chronic problems like with growing brain tumor”nAssociated fundal hge indicates acute and severe rise in ICP17428 surgery team18428 surgery
16、 teamGCS “very imp to asses the severity of coma”Decreased Level of ConsciousnessIts a coma score not a weakness score.The patient takes 6 even he is with hemiplagia19428 surgery teamnWhen it comes to head injury there a classification of GCS:nMild GCS= 13 15 nModerate GCS= 9 12nSevere GCS= 3 8nThe
17、lowest number in GCS is 3 and the highest number is 1520428 surgery teamnNeurological:nPupillary dilation nHemiplegianCranial nerve deficit21428 surgery teammissinglink.ucsf.edu/./ HerniationGross.jpg22428 surgery team23428 surgery teamnIf there is a mass compressing the 3rd nerve So, ipsilateral pu
18、pil dilation and compression on the brain stem will give you contralateral hemiplasia ”weakness”.missinglink.ucsf.edu/./ TentorialNotchBlum.jpg24428 surgery teamTrans-tentorial herniation: - Ipsilateral dilated pupil - Contra-lateral weakness25428 surgery teammissinglink.ucsf.edu/./ tonsillar%20hern
19、-2a.jpgTonsillar herniation26428 surgery teamFalse localizationnKernohans notchSimply, when there is a huge growing right side hematoma it will push the whole brain stem tothe opposite side and that may cause ipsilateral weakness and contra-lateral dilated pupil27428 surgery teamnSystemic:nRaised BP
20、 (recall: CPP=MAP-ICP)nRespiratory change:nCheyne-Stokes breathing:nOscillating periods of apnea-tachypneanRespiratory centers compromise28428 surgery teamRaised ICP in infants results in:nWidened suturesnIncreased Head circumferencenDilated head veinsn“Sun set” eyes “his eyes always looking down”29
21、428 surgery team30428 surgery teamInvestigationsnURGENT CT headnNO Lumbar Puncture until you do at least the CT31428 surgery teamWhat is the treatment of high ICP?nGeneral measures:nHead elevation (30 degrees)nNo neck compressionnMannitol for patients who have decreased LOC (or Furosemide)nSteroids
22、(Dexamethazone) for tumors nHyperventilation: controlled to PCO2 35-40 mmHgnSedation, muscle relaxantsnHypothermianBarbiturates: terminal option LOC: Level Of Consciousness32428 surgery teamWhat is the treatment of high ICP?nSpecific treatment:nDepends on the causenVITAMEN D remember stands for what
23、?33428 surgery teamVascular - SAH / ICH archives2007/COW%20.www.musc.edu/./Fall2003/ Theodosha/brain31.gifradiology.rsna.org/ content/244/3/923/F1.large.jpg34428 surgery teamInfection - Abscess35428 surgery teamTraumanLocalizedEpidural HematomaSubdural Hematoma36428 surgery teamTraumanD ./cow315-1arr.jpg37428 surgery teamTumorMeningiomaGlioblastoma Multiformi38428 surgery teamHydrocephalusTreated with shunt39428 surgery teamCan we monitor ICP?forum.interes.ge/index. php?showtopic=564&st=2040428 surgery team
