Approach To Increased Intracranial

Pressure and Intervention Option

in Emergency Settings

Department of Neurosurgery, Dr. Cipto Mangunkusumo Hospital (RSCM)

Faculty of Medicine, Universitas Indonesia (FKUI)

dr. Ande Fachniadin, Sp.BS

Instagram Tiktok: @cuneuspldui / Contact Person: Indira (085172003186)

INTRODUCTION
Intracranial Pressure
•A pressure measured inside intracranial
• As a result of components which occupy intracranial space

•Measured in mmHg or 2
HO

•Normal value : 5-15 mmHg

Reference:
Mokri B. The Monro-Kellie hypothesis: applications in CSF volume depletion. Neurology. 2001 Jun 26;56(12):1746-8
Intracranial Component
CSF 10%
Blood 10%

Brain Parenchyma
80%

Reference:
Monro Kellie Doctrine

the contents of the

cranium are
in a state of
constant volume
Monro Kellie Doctrine
the contents of the cranium are
in a state of constant volume

• An increase volume of one component should be

compensated by other
• An additional mass (lesion) should be compensated
by the components
• Uncompensated status will be occurred once the
critical point reached.
 CPP = MAP - ICP

Oswal, A., & Toma, A. K. (2020). Intracranial pressure and cerebral haemodynamics. Anaesthesia & Intensive Care Medicine.
Wang J., Altaweel L. (2017) Hemodynamic Considerations in the Polytrauma Patient with Traumatic Brain Injury (TBI). In: Ecklund J., Moores L. (eds) Neurotrauma Management for the Severely Injured
PolytraumaPatient. Springer, Cham.
Etiology CSF dynamics:
- Increase of CSF volume
- Obstruction (e.g Hydrocephalus)
- Over-production (e.g tumor of ch plexus)
- Decrease of CSF absorption
- Inflammation of Pachionnian granulation
(e.g Meningitis)

Blood volume:
- Increase of Cerebral Blood Flow
- Hypercarbia
- Cerebral venous thrombosis
- Elevated central venous pressure
- Chronic heart failure

Brain tissue volume

- Mass effect
- Brain edema
- Traumatic brain edema
- Malignant infarction
Mass
- Blood outside the vessel (Hematoma)
- Tumor
- Intrinsic (e.g meningioma)
- Extrinsic (e.g glioma)
- Abscess
- Foreign body

Other cause
- Idiopathic
- Skull deformities (primary craniosynostosis)
DIAGNOSIS
Diagnosis
• Anamnesis

• Physical diagnosis

• Other Examination
Algorithm Summary
Anamnesis Physical Exam Imaging Management
• Headache
• CT/MRI Scan • Pharmacology
• Vomitting • Altered consciousness
• Mannitol
• Decrease conciouseness • Visual Acquity disrutbance
• CAI
• Funduscopy – Papil Edema
• Surgery
• Infant  bulging fontanele
• VP Shunt
• Hemodinamic
• EVD
• Cushing triad
• Decompresive Craniectomy
Clinical Manifestation
• Headache
• Vomitting
• Altered mental status
• Altered consciousness
• Visual Changes
• Infant  bulging fontanele
• Cushing triad
Cushing Triad
Funduscopy
Step of Funduscopy
• Informed consent of side effect from dilated pupil
• Midriatil (Tropicamid 1%)
• Wait for 15 minutes
• Check if pupil already dilated
• Check the eye with funduscopy device
Papilledema
• Blurred boundaries
• The blood vessels
are enlarged and
tortuous
• Dense pink disc
• Swollen disc
Papil Atrophy
Primary Secondary
Imaging

Malignant Intracerebral
Hydrocephalus
Ischemic Stroke Hemmorhage
Imaging

Brain Tumor Primary Craniosynostosis

Management
Management
•Always attempt to find the cause!
•Identify the emergency
• Sudden onset
• Rapid deterioration
•Target:
• Lowering ICP
• Treat underlying cause
• Maintain CPP
Hawryluk GWJ, Aguilera S, Buki A, et al. A management algorithm for patients with intracranial pressure
monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 2019;45:1783-94; Carney N, Totten AM,
O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017;80:6-15.
Head up 30 o
Osmotic Agent
• Manitol
• Dose 0.25 to 1 g/kg BW
• Bolus rapid
• Observe : urine production, serum osmolarity, hemodynamic

• Hypertonic Saline
• Dose 5 ml/kg
• Bolus or continuous infusion
• Observe : serum electrolyte, central pontine myelolysis
Steroids
• Dexamethasone
• Improve blood brain barrier and vascular
permeability
• Dose (initial) 10 mg iv bolus (maintenance) 5mg-10
mg ; 3-4 times daily, max
dose may up to 100 mg/day

• Caution: Brain Tumor

• gastric ulcer,
• tapering down dosage,
• Long term side effect
• Other steroids may substitute:
methylprednisolone
Carbonic Anhidrase Inhibitor
• Reduce CSF production
• Asetazolamide

• Dose: 250 – 500 mg, 2-3 times daily

• Caution: long term electrolyte imbalance

Hydrocephalus
CSF Diversion
Intraventricular Hemmorhage

• Depends on underlying cause

• VP Shunt
• EVD
• Lumbal puncture
• Optic nerve fenestration
EVD
Decompressive craniectomy

At 6 months, decompressive craniectomy in patients with traumatic brain injury and refractory intracranial
hypertension resulted in lower mortality and higher rates of vegetative state, lower severe disability, and
upper severe disability than medical care.
Case
CASE 1
• Perempuan 53 tahun
• GCS E2M5V2
• Penurunan kesadaran 2 jam
• Pupil anisocor, 4/3mm
sebelum masuk rumah sakit
• Hemiparesis kiri
• Riwayat kelemahan sisi tubuh
kiri sejak 2 hari yang lalu
• Tekanan darah 180/90 mmHg
• Riwayat hipertensi dan
• Nadi 60x/m
dislipidemia
CASE 1

Insert Image
CASE 2
• Laki – laki 47 tahun
• Tampak semakin mengantuk • GCS E3M6V4
sejak 1 minggu yang lalu • Pupil isocor, 3mm
• Muntah muntah sejak 5 jam • Kaku kuduk +
yang lalu • Tidak ada hemiparesis
• Riwayat demam sejak 2
minggu terakhir
CASE 2
TERIMA KASIH