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Intracranial Pressure
ALL NUMBERS GIVEN ARE ISH

The Good, Bad & Ugly

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Neurological
Pathophysiology

The cranial vault is a fixed space consisting of

3 compartments:

Structural changes or damage

Circulatory changes
Alterations in intracranial pressure (ICP)

Parenchyma (neurons and neuroglial tissue) - 80%

CSF - 10%
Blood - 10%

Three structures in the intracranial space:

Therefore, expansion of one compartment

results in a compensatory decrease in another
in order to maintain ICP

Brain tissue
Blood
Water

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Intracranial Space

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Intracranial Space

Brain tissue
Mostly water, intracellular and extracellular
Blood - Intracranial circulation of blood is about 1000
liters per day delivered at a pressure of 100 mmHg and
at any given time
time, the cranium contains 75 ml (ish)
Major arteries in base of brain
Arterial branches, arterioles, capillaries, venules,
veins within brain substance
Cortical veins and dural sinuses

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Monroe-Kellie Doctrine

Cerebral blood flow (CBF) interrupted by:

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Water in:
Ventricles of brain
Cerebrospinal fluid
Is constantly secreted, and after circulating,
absorbed at an equal rate
CSF circulation is slow (500 to 700 ml/day)
At a given time the cranium contains 75 ml of
CSF

Extracellular and intracellular fluid

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Cerebral Perfusion Pressure

(CPP)
Cerebral blood flow depends on cerebral
perfusion pressure
Cerebral blood flow controls oxygen and
glucose delivery and waste removal
It depends on the pressure gradient across
brain

Important Concepts

Cerebral perfusion pressure (CPP) and cerebral

vascular bed resistance
CPP determined by:
Mean arterial pressure (MAP): (Diastolic pressure +
pulse pressure) minus intracranial pressure
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Cerebral Perfusion Pressure

< 50 mm Hg - Mild cerebral ischemia

< 40 mm Hg - Cerebral blood flow down
25%
< 30 mm Hg - Irreversible cerebral
ischemia
If MAP = ICP there is no gradient

Subtract ICP from MAP

Example:
Patient has an ICP of 80 and a MAP of 113
113 MAP
- 80 ICP
= 33 CPP (BAD)

Best if > 70 mm Hg
< 60 mm Hg = impaired blood flow to brain
Can lead to seizure, coma and death
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Hence, there is no blood flow to the brain

and brain death in imminent (seizure coma
death)
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Cerebral Blood Flow

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The main regulator of brain blood flow is

pressure - dependent activation of smooth
muscle in the arterioles of the brain. The
more the arteriole is stretched, the more it
contracts, and this lasts as long as the
stretch occurs

Gradient for flow decreases

Cerebral blood flow restricted

When ICP increases,

increases CPP decreases
As CPP decreases, cerebral vasodilation
occurs
Increases cerebral blood volume
(increasing ICP) and further cerebral
vasodilation
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Autoregulation Of
Cerebral Blood Flow

As ICP approaches MAP:

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The Bottom Line

Calculate CPP

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More ICP (Bad)

So
So
Equals Less LOC
(Also Bad)

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What Is Normal ICP?

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Hip flexion
(decreases venous
return)
H d and
Head
d neck
k position
iti
Changing level of height
of bed (especially flat)
External noxious stimuli

Agitation
Pain
Coughing and
valsalva
maneuver
Seizures

Treatment

Decrease external stimulation

Ensure a quiet environment
Pull slouching patients to the top of the
b d
bed
Use cervical collar with decreased neck
muscle tone
Shut off bright lights
Align head and neck
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What Can You Do?

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Factors Which Increase ICP

0 to 15mm Hg in an adult (depends on

where you look)
Most text list it as < 15mm Hg

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Ventilation:
What is optimal PaO2 level?
Keep PaO2 between 90-120mmHg or SPO2

What is the optimal PaCO

CO2
Old method Keep PaCO2 at 25 mmHg
New method Keep PaCO2 range 30-35
mmHg

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Treatment
Analgesia and Sedation
Reduces movement
Helps with ventilation
Reduces perceived pain
Limits responses to procedures such as
suctioning

Of Course

A lot of different ones fentanyl,

midazolam, propofol etc
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If you feel up to it, there is always

surgery

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Glasgow coma score <8

Abnormal CT scan - 50-60% risk
Normal CT Scan, Age > 40 or BP < 90mmHg or abnormal
motor posturing - 50-60% risk
Normal CT scan with no risk factors - 13% risk

Glasgow coma score 9 to 12

If paralytic and/or sedative medications are being used or
abnormal CT scan - 10-20% will deteriorate to severe head
injury

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A Little Bit About ICP

Monitoring

g y by
y numbers?
Surgery

ICP Monitoring - Indications

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Devices
Interventricular cannula (IVC)
Epidural catheter
Subdural / subarachnoid monitoring
devices
Fiber optic transducer tipped probe

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Interventricular Cannula (IVC)

IVC

Most commonly used

monitor
Placed within the
ventricle

Interventricular Cannula
(IVC)
Advantages
Drain CSF to lower
ICP
Obtain CSF cultures
Increased accuracy
in ICP monitoring
Accurate and reliable

Disadvantages
Infection
Injury to brain
Clot formation
Hemorrhage risk
Collapsed ventricle
Placement may be
impossible

Abnormal Wave Forms

Interventricular Cannula
(IVC)
Transport considerations
System set-up
Charting
g ICP
Drainage orders
Movement
Pressure changes with air transport

Abnormal Wave Forms

P2 > P1 Autoregulation gone and

things are swirling the drain. A waves
are next
Things Are Headed South

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Questions?

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