Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
PATHOPHYSIOLOGY
MODERATOR: Dr VENKATESH
PRESENTED BY: DR KHAWER
MUNEER
Intracranial pressure
Intracranial pressure refers to the pressure within the
intracranial vault (skull).
It is the pressure exerted by the total volume from
the brain tissue, blood, and CSF.
Intracranial pressure is important as it affects
cerebral perfusion pressure and cerebral blood flow.
Normal ICP is between 5 and 15mmHg.
Because it is very dependant on posture, the external
auditory meatus is usually used as the zero point.
Intracranial pressure
Constituents within the skull include the brain (80%/1400ml), blood
(10%/150ml) and cerebrospinal fluid (CSF 10%/150ml)
The skull is a rigid box so if one of the three components increases
in volume, then there must be compensation by a decrease in the
volume of one or more of the remaining components otherwise the
ICP will increase (Monro-Kellie hypothesis).
The term compliance is often used to describe this relationship, but
it is more accurately elastance (change in pressure for unit change
in volume)
CONTROL OF CBF AND CBV--Various factors discussed below affect CBF and CBV which in
turn control ICP
Presentation: Symptoms
Headache
Visual changes
Nausea
Vomiting
Behavior changes
Altered consciousness: irritability to obtundation or
coma.
Seizures
Nuchal rigidity
Focal neurologic deficit
Presentation: Symptoms
Infants may present with less specific
symptoms
Irritability
Bulging fontanel
Lethargy
Poor feeding
Presentation: signs
Papilledema
Retinal haemorrhages
Dilated pupil: usually on the side of the lesion
Cranial nerve palsies of the third, fourth, and sixth cranial
nerves
Hemiparesis, hyperreflexia, and hypertonia: are late signs
Cushing triad: another late sign, and may be a preterminal
event
Presentation: signs
Infants may develop
Macrocephaly
Split sutures
Bulging fontanel
Hydrocephalus: Sun setting" appearance of the eyes may
appear
Cushings Triad
Systolic pressure increases (widened pulse pressure
results).
Slowing of heart occursbradycardia (occurs as result
of reflexive slowing in response to increased systolic
pressure)
Respiration changesbecomes slowed
herniation
Tier Zero:
HOB > 30 degrees
ensure adequate sedation
correct hyponatremia, hyperthermia, and vasogenic
edema
keep CPP > 60-70 mm Hg
**normocarbia (PaCO2 35-45)
**good oxygenation (PaO2 >100)
Tier One:
secure airway
mannitol0.5-1 gm/kg IV bolus
start3% saline10-20 cc/hr
CSF drainage
Tier Two:
hypertonic salinebolus (3%-23.4%)
considerpropofolbolus and infusion
considerdecompressive craniotomy
Tier Three:
Intracranial pressure thresholds-- Treating ICP > 22 mm Hg is recommended because values above this level are
associated with increased mortality (Level IIB).
A combination of ICP values and clinical and brain C T findings may be used to
make management decisions (Level III).
Cerebral perfusion pressure thresholds--
The recommended target CPP value for survival and favorable outcomes is
between 60 and 70 mm Hg. Whether 60 or 70 mm Hg is the minimum optimal CPP
threshold is unclear and may depend upon the autoregulatory status of the patient
(Level IIB).
Avoiding aggressive attempts to maintain CPP > 70 mm Hg with fluids and pressors
may be considered because of the risk of adult respiratory failure (Level III)
Treatment Recommendations
Prophylactic hypothermia ----
Early (within 2.5 h), short-term (48 h post-injury), prophylactic hypothermia is not
recommended to improve outcomes in patients with diffuse injury.
Hyperosmolar therapy-----
Mannitol is effective for control of raised ICP at doses of 0.25 to 1 g/kg body
weight. Arterial hypotension (systolic blood pressure < 90 mm Hg) should be avoided.
Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial
herniation or progressive neurologic deterioration not attributable to extracranial
causes
Cerebrospinal fluid drainage --An EVD system zeroed at the midbrain with continuous drainage of CSF
may be considered to lower ICP burden more effectively than
intermittent use
Use of CSF drainage to lower ICP in patients with an initial GCS ,6
during the first 12 h after injury may be considered.
(Level IIB)
Steroids---
The use of steroids is not recommended for improving outcome or reducing ICP. In
patients with severe TBI, high dose methylprednisolone was associated with
increased mortality and is contraindicated.
Nutrition
Feeding patients to attain basal caloric replacement at least by the fifth day and
at most by the seventh day post-injury is recommended to decrease mortality.
Seizure prophylaxis
Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS.
Phenytoin is recommended to decrease the incidence of early PTS (within 7 d of injury),
when the overall benefit is thought to outweigh the complications associated with such
treatment. However, early PTS have not been associated with worse outcomes
At the present time there is insufficient evidence to recommend levetiracetam compared
with phenytoin regarding efficacy in preventing early post-traumatic seizures and toxicity.
ICP waveform--
Measurement of icp
Ventriculostomy
Intraparenchymal monitor
Epidural/subdural catheter
Subarachnoid screw
ventriculostomy
The ventriculostomy is also referred to as the
intraventricular catheter or ventriculostomy drain.
It is a soft tube placed through a burr hole into the
lateral ventricle of the brain. The tubing connects to a
standard transducer set which is never pressurized.
It is the most accurate way to receive and monitor an
ICP.
The ventriculostomy also allows for the therapeutic
drainage of CSF.
Intraparenchymal monitor
The intraparenchymal or a fiberoptic transduced
tipped catheter is seen very often in the ICU.
It is the second most accurate way to obtain an ICP.
There is no way to drain CSF, but infection and
hemorrhage rates are low.
Epidural/subdural catheter
The subdural/epidural catheter is another method to
monitor ICP.
It is less invasive but also less accurate.
It cannot be used to drain CSF.
The catheter has a lower risk of infection or hemorrhage
Subarachnoid screw
The subarachnoid screw, also known as a bolt,
connects to an external traducer via tubing.
It is placed into the skull abutting the dura. It is hollow
screw which allows CSF to fill the bolt, allowing the
pressures to become equal.
The positives of this method are that infection and
hemorrhage risks are low.
The negative aspects include the possibility of errors
from ICP underestimation, misplacement of the screw,
and occlusion by debris
COMPLICATIONS OF ICP
MONITORING
Infection
in CBF at Doses higher than 1 MAC could reflect uncoupling of flow and metabolism
BARBITURATES
Dose dependent in CMR and CBF until EEG becomes
isoelectric
Unlike isoflurane, barbiturates reduce metabolic rate
uniformly throughout the brain.
Barbiturates also seem to facilitate absorption of CSF.
Their anticonvulsant properties are also advantageous in
neurosurgical patients who are at increased risk of seizures.
Agent
CMR
CBF
CSF
CSF
CBV
Productio Absorptio
n
n
ICP
Halothane
Isoflurane
Desflurane
Sevoflurane
Nitrous
Oxide
Barbiturate
s
Etomidate
Propofol
BZD
Ketamine
, increase; ,
unknown; CMR,
rate;
Opoids
decrease;, little or no
change; ?,
cerebral metabolic
CBF, cerebral blood fl ow; CSF, cerebrospinal fluid; CBV, cerebral blood volume; ICP,
intracranial pressure.
thankyou