surg351 presentation and management of raised intracranial pressure

Presentation & Management of

Raised Intracranial Pressure

ByBy

ZainZain AlabedeenAlabedeen B. B. JamjoomJamjoom, M.D., M.D.

Professor of NeurosurgeryProfessor of Neurosurgery

20 November 2007 Raised ICP 2

Normal Intracranial Pressure

�� Normal ICP ~10 mmHg Normal ICP ~10 mmHg (supine at the level of the foramen of (supine at the level of the foramen of MonroMonro))

�� Pulsatile Pulsatile

�� Fluctuates with the respirationFluctuates with the respiration

�� ICP >20 mmHg is definitely pathologicalICP >20 mmHg is definitely pathological


Normal ICP Waveformt (sec)

ICP

ECG

Resp.


Cerebral Blood Flow (CBF)

�� Flow = Flow =

�� CBF = CBF =

�� CPPCPP = Mean = Mean systsyst. art. BP . art. BP -- Mean ICPMean ICP

Cerebral perfusion pressure (CPP)Cerebral perfusion pressure (CPP)

Cerebral vascular resistance (CVR)Cerebral vascular resistance (CVR)

PressurePressure

Resistance Resistance


Intracranial Cavity

�� Its volume is virtually constant. Its volume is virtually constant.

�� It is filled to capacity with fluids & solid It is filled to capacity with fluids & solid

material that are nonmaterial that are non--compressible. compressible.

�� ThereforeTherefore: :

Increase in one constituent or an Increase in one constituent or an

expanding mass within the intracranial expanding mass within the intracranial

space results in raised ICP space results in raised ICP ((MonroMonro--Kellie Kellie

Doctrine)Doctrine). .


Intracranial Cavity

Content

�� Brain:Brain:

–– NeuronesNeurones 500 500 -- 700 ml700 ml

–– GliaGlia 700 700 -- 900 ml900 ml

–– ExtracellularExtracellular fluid 100 fluid 100 -- 150 ml150 ml

�� Blood: Blood: 100 100 -- 150 ml150 ml

�� Cerebrospinal fluid: Cerebrospinal fluid: 100 100 -- 150 ml150 ml

Constituents are nonConstituents are non--compressible compressible

but partially displaceablebut partially displaceable


ICP/Volume Curve


Intracranial Cavity

3 compartments

�� 2 2 supratentorialsupratentorial

spaces, separated spaces, separated

by the by the falxfalx cerebricerebri, ,

andand

�� 1 infratentorial1 infratentorial

space, separated space, separated

from from supratentorialsupratentorial

spaces by the spaces by the

tentoriumtentorium..


Intracranial Mass

Shifts

(Cerebral

Herniations)


Transtentorial (Uncal) Herniation

Bilateral

Unilateral


The Tentorial

Hiatus

Oculomotor nerve

Posterior cerebral artery

Cerebral peduncle

Reticular formation


Transtentorial Herniation

�� Compression of 3Compression of 3rdrdCN: CN:

–– Dilatation of Dilatation of ipsilateralipsilateral pupil.pupil.

�� Compression of the midCompression of the mid--brain:brain:–– Impairment of consciousness.Impairment of consciousness.

–– HemiparesisHemiparesis (usually (usually contralateralcontralateral, but , but occasionally occasionally ipsilateralipsilateral).).

–– Hypertension + Hypertension + BradycardiaBradycardia (Cushing response).(Cushing response).

–– Respiratory failure.Respiratory failure.

�� Compression of post. cerebral artery:Compression of post. cerebral artery:

–– Infarction of occipital lobeInfarction of occipital lobe


Syndrome

of Unilateral

Uncal

Herniation

Early Phase


Syndrome

of

Unilateral

Uncal

Herniation

Late Phase


A main cause of uncal herniation

is Extradural Hematoma


Clinical Symptoms & Signs of

Raised ICP

�� HeadacheHeadache

�� Nausea and vomitingNausea and vomiting

�� PapilledemaPapilledema

�� Impairment of consciousnessImpairment of consciousness

�� 66ththcranial nerve palsy: False cranial nerve palsy: False

localizing signlocalizing sign

�� Impaired level of consciousnessImpaired level of consciousness


Signs of Raised ICP

Normal Papilledema

Papilledema


Signs of Raised ICP

Abducent Nerve Palsy


Clinical Symptoms & Signs of

Raised ICP in Infants

�� Large head (Large head (MacrocephalyMacrocephaly))

�� Tense & enlarged anterior Tense & enlarged anterior

fontanelfontanel

�� Separated skull suturesSeparated skull sutures

�� Prominent scalp veinsProminent scalp veins

�� ““Sun setSun set”” of eyesof eyes


Macrocephaly


Investigations

�� Method of choice:Method of choice:

URGENTURGENT brain CT scan.brain CT scan.

�� Skull XSkull X--rays:rays:

–– Separated suturesSeparated sutures

–– Silver beaten appearanceSilver beaten appearance

�� Lumbar puncture isLumbar puncture is

CONTRAINDICATEDCONTRAINDICATED..


Separated Skull Sutures


Silver Beaten Appearance


Causes of Increased ICP

�� Increased volume of normal intracranial Increased volume of normal intracranial

constituents:constituents:

–– Brain: Cerebral edema.Brain: Cerebral edema.

–– Cerebrospinal fluid: Hydrocephalus.Cerebrospinal fluid: Hydrocephalus.

–– Blood volume: Vasodilatation 2Blood volume: Vasodilatation 2ooto COto CO22

�� A spaceA space--occupying lesion:occupying lesion:

-- TumorTumor -- Hematoma Hematoma

-- AbscessAbscess -- CystCyst

�� Idiopathic: Idiopathic:

–– PseudotumorPseudotumor cerebricerebri


Cerebral Edema


Hydrocephalus


Intracranial

Tumor


Intracranial Tumors

�� Intrinsic: Intrinsic:

–– Arise from brain tissueArise from brain tissue

–– Majority are Majority are gliomasgliomas (Grades I to IV)(Grades I to IV)

�� Extrinsic: Extrinsic:

–– Arise from intracranial tissue other than brainArise from intracranial tissue other than brain

–– Include: Meningioma, Pituitary adenoma, Include: Meningioma, Pituitary adenoma, SchwannomaSchwannoma

�� Location:Location:

–– Adults: mainly Adults: mainly supratentorialsupratentorial

–– Children: mainly Children: mainly intratentorialintratentorial


Brain Abcsess


Brain Abscess

�� Develop as a result of a localized Develop as a result of a localized bacterial bacterial cerebritiscerebritis followed by necrosis followed by necrosis and encapsulation.and encapsulation.

�� Mechanisms:Mechanisms:

–– HematogenousHematogenous

–– Extension from Extension from neighbouringneighbouring structuresstructures

–– Penetrating injuriesPenetrating injuries

�� Symptoms of infection may be absent in Symptoms of infection may be absent in 50% of cases 50% of cases


Treatment of Raised ICP

�� General measures for reducing General measures for reducing

raised ICPraised ICP

�� Definitive treatment:Definitive treatment:

Removal of the causeRemoval of the cause


General Measures to Reduce Raised ICP

�� Head elevation 30Head elevation 30ooup in neutral position.up in neutral position.

�� Diuretics:Diuretics:

–– MannitolMannitol : 20% 1g/kg iv single dose or : 20% 1g/kg iv single dose or 0.250.25--0.5g/kg Q8h0.5g/kg Q8h

–– FurosemideFurosemide : 1mg/kg iv : 1mg/kg iv sinlglesinlgle dose or dose or 0.250.25--.05mg/kg Q8h.05mg/kg Q8h

�� NormovolemiaNormovolemia: IV infusion of : IV infusion of cristalloidcristalloid

�� Controlled hyperventilation:Controlled hyperventilation:

–– pCO2 reduction to 30 pCO2 reduction to 30 -- 35 mmHg.35 mmHg.

�� Sedation & Muscle relaxation.Sedation & Muscle relaxation.

�� CSF withdrawal. CSF withdrawal. No lumbar punctureNo lumbar puncture


Ventriculo-peritoneal Shunt


Excision of Intracranial Tumor


Drainage of Brain Abscess


Benign Intracranial Hpertension

“Pseudotumor cerebri”

�� Young, obese womenYoung, obese women

�� Pathogenesis not clearPathogenesis not clear

�� Precipitating factors:Precipitating factors:

–– HypoparathyroidismHypoparathyroidism

–– Vitamin A excess (Vitamin A excess (TxTx of acne)of acne)

–– Pernicious anemiaPernicious anemia

–– Drugs: oral contraceptives, tetracycline, Drugs: oral contraceptives, tetracycline, sulphamethoxazolesulphamethoxazole, , indomethacinindomethacin, a.o., a.o.


Benign Intracranial Hypertension

Presenting Features

�� HeadacheHeadache

�� Visual disturbanceVisual disturbance

–– Blurred visionBlurred vision

–– DiplopiaDiplopia

�� PapilledemaPapilledema

�� Optic atrophyOptic atrophy

�� 66thth nerve palsynerve palsy


�� CT CT –– scan: WNLscan: WNL

�� Lumbar puncture & measurement of Lumbar puncture & measurement of

CSF pressure: ElevatedCSF pressure: Elevated

�� CSF biochemical & cytological: WNLCSF biochemical & cytological: WNL

�� MRI & MRA: WNLMRI & MRA: WNL

�� Continuous intracranial pressure Continuous intracranial pressure

measurement (in doubtful cases) measurement (in doubtful cases)


Investigations



Treatment

�� Weight reductionWeight reduction

�� Discontinuation of potentially causative Discontinuation of potentially causative

drugs ( e.g. contraceptives, vitamin A)drugs ( e.g. contraceptives, vitamin A)

�� Diuretics (e.g. Diuretics (e.g. LasixLasixRR))

�� AcetazolamideAcetazolamide ((DiamoxDiamoxRR): Initially 500 ): Initially 500

mg, later 250 Q6hmg, later 250 Q6h

�� Intermittent release of CSFIntermittent release of CSF



Indication of Surgery

�� Persistent papilledema despite Persistent papilledema despite TxTx

�� Failing visionFailing vision

�� Intractable headache despite Intractable headache despite TxTx



Surgical Treatment

�� LumboLumbo--peritoneal shuntperitoneal shunt

�� Optic nerve sheath decompressionOptic nerve sheath decompression


Complications of Untreated

Raised ICP

�� DeathDeath

�� Neurological disabilityNeurological disability

–– BlindnessBlindness

–– Mental impairmentMental impairment

–– Motor disabilityMotor disability

�� DisfigurementDisfigurement


Neurological Disability


Measurement of Intracranial

Pressure

�� EpiduralEpidural

�� SubduralSubdural

�� IntraparenchymalIntraparenchymal

�� IntraventricularIntraventricular


Intraventricular Pressure Measurement


A-waves or Plateau waves


Measurement of Intracranial

Pressure Indications

�� Severe head traumaSevere head trauma

�� IntracerebralIntracerebral hemorrhagehemorrhage

�� Extensive cerebral edema Extensive cerebral edema

–– e.g. after infarct, hypoxia, intoxication, etc.e.g. after infarct, hypoxia, intoxication, etc.

�� Following major intracranial operationsFollowing major intracranial operations

�� In the assessment of dementia and In the assessment of dementia and

benign intracranial hypertensionbenign intracranial hypertension


References

�� Essential NeurosurgeryEssential Neurosurgery

by: Andrew Kayeby: Andrew Kaye

�� Neurology and Neurosurgery IllustratedNeurology and Neurosurgery Illustrated

by: Lindsay by: Lindsay -- Bone Bone -- CallanderCallander

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