Increased Intracranial Pressure Intracranial pressure (ICP) is the pressure in the skull that results from the volume

of three essential components: cerebrospinal fluid (CSF), intracranial blood volume and central nervous system tissue. The normal intracranial pressure is between 5-15 mmHg. This is slightly lower than the mean systemic arterial pressure but considerably higher than venous pressure. The intact cranium is essentially inexpandable containing about 1400 grams of central nervous system (CNS) or brain tissue, 75 ml of blood and about 75 ml of cerebrospinal fluid (CSF). These three components of the cranial vault maintain a state of equilibrium. Their pressure and volume determine the condition of balance. According to Monro-Kellie hypothesis, any increase in one of these elements must be balanced or compensated by a proportional constriction either or both of the other two components such as decreasing the volume of cerebral blood flow, shifting CSF flow (into the spinal canal) or increasing CSF absorption. Absence of these compensatory changes results to increased intracranial pressure. Once ICP reaches around25 mmHg marked elevation in intracranial pressure will be noted. CSF is formed from the blood by the choroid plexuses, which are hanging at the roof of the brains ventricles. From the point where it is produced, it flows through the aqueduct of Sylvius to the fourth ventricles. Three apertures (opening) are found in the fourth ventricle which serves as passageway going to the subarachnoid spaces in the brain and spinal cord. These openings are Foramina of Magendie (median aperture) and two Foramina of Luschka (lateral apertures). A presence of tumor in choroid plexus may cause an overproduction of CSF. If the passageway of CSF is obstructed or brain tissue damage during surgery occurs, elevated ICP is inevitable. Normally, a change in CSF and blood volume occurs. For instance, during exhalation a temporary rise in intrathoracic pressure occurs. This impairs cerebral venous drainage and thereby reabsorption of CSF. An increase in ICP might likely occur, unless the blood will be expelled or the brain tissue will shrink (compensatory mechanism). If no compensation will occur, based on Monro-Kellie hypothesis, a slight increase in intracranial pressure will take place. The same process occurs during Valsalva maneuver (forcible exhalation against a closed glottis), sneezing, coughing and straining at stool. This is the main reason why people with increase ICP and at risk for cerebral hemorrhage are instructed to avoid these instances.

Presence of carbon dioxide can also increase ICP. Carbon dioxide is a potent vasodilator that dilates aretrioles (including those in the chorionic plexus in the brain) which elevates cerebral blood volume and ICP. Etiology CSF hydrocephalus

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Overproduction of CSF Meningitis Subarachnoid hemorrhage Brain tumor Impediment of CSF flow Narrowed foramina of Magendie and Luschka Obstruction in the Aqueduct of Sylvius Arnold-Chiari disorder Interference with CSF absorption Surgery Head injury Cerebral edema Cerebral venous sinus thrombosis Hematoma Increased carbon dioxide partial pressure Medical Surgical Nursing by Smeltzer and Bare Pathophysiology by Nowak and Handford

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DEFINITON Neural tube defects (NTDs) are birth defects of either the brain or spinal cord. This group of disorders is characterized by an opening in the brain or spinal cord occurring at an early stage of human development. Incidence NTDs are one of the most common birth defects.

Spina Bifida Occulta occurs when the posterior laminae of the vertebra fail to fuse at 26-28 days age of gestation. The most common site is the fifth lumbar or sacral level though it may occur at any point along the spinal canal.

Meningocele herniation of the meninges through the unformed vertebrae of the spinal cord. Generally, it occurs at the lumbar area but it can be present anywhere along the spinal canal. It is characterized by an appearance of an orange-shaped mass at the center of the back.

Female predominance is observed. About 60-70% of all cases are females. The incidence of neural tube disorders have fallen dramatically in recent years from 3 cases in every 1000 births to only 0.6 cases in every 1000 births.

Risk Factors

Myelomeningocele herniation of the spinal cord and meninges through the unformed vertebrae. The spinal cord ends at the pint of protrusion, thus, motor and sensory function beyond the point of herniation is absent.

Cigarette smoking and maternal exposure to cigarette smoke Maternal diabetes Maternal obesity Polygenic inheritance pattern Poor maternal nutrition Maternal diet deficient in folic acid Intake of folate antimetabolites (methotrexate) Use of teratogens

Causes

images from neuropathologyweb.org, bio.davidson.edu, neurosurgery.ufl.edu

Review of the related anatomy and physiology The central nervous system is the first observable structure in a human embryo. This embryo passes through 23 stages of development after conception. Two processes work in order to form the CNS: 1. 2. Primary neurolation Secondary neurolation

Primary neurolation is the formation of the neural structures into a tube. This forms the brain and the spinal cord. Secondary neurolation is the formation of the lower spinal cord. This gives rise to the lumbar and sacral elements. Types of Neural Tube disorders

Anencephaly absence of the cerebral hemispheres. Closure of the anterior neuropore occurs at stage 11 at about 23-26 days age of gestation. Failure of this point to close results to anencephaly. Children with this disorder cannot survive because of the absence of cerebral function. These children may only survive for a number days because the respiratory and cardiac centers are located in the intact medulla.

Microcephaly characterized by a slow brain growth. Generally, infants with this disorder are cognitively challenged because of the lack of functioning brain tissue. The head circumference of affected neonates is decreased.