Dr.

Ellen Safadi
Increase ICP PART (I & II)

https://www.barnesjewish.org/Medical-Services/Neurology-Neuros
urgery/Neurosurgery-Procedures
https://en.wikipedia.org/wiki/Neurosurgery
April 22, 2024

www.gmu.ac.ae
Learning Objectives:
On completion of this unit, the student will be able to:
• Revise the Anatomy & physiology of the nervous system.
• Discuss the Intracranial Pressures.
• Relate the Monro-Kellie hypothesis with regulatory system.
• Discuss Intracranial Pressure stages.
• Calculate Cerebral perfusion pressure.
• Discuss the causes of IICP.
• Know the Signs & Symptoms of IICP.
• Know the measures of IICP Management.
Contents
• Anatomy & physiology.
• Intracranial Pressure.
• The Monro-Kellie hypothesis.
• Intracranial Pressure stages.
• Cerebral perfusion pressure.
• Causes of IICP.
• Signs & Symptoms of IICP.
• IICP Management.
Brain anatomy
Brain Anatomy
CSF Flow
• The CSF occupies the subarachnoid space, providing a
protective layer of fluid between the CNS and the tissue that
surrounds it.

CSF is produced by the choroid plexus in the ventricles at

about 0.3 mL/min.
CSF circulation
CSF circulation follows the path
 from the lateral ventricles Into the third ventricle via the interventricular
foramina (foramina of Monro).
It subsequently transits through the cerebral aqueduct of Sylvius into the
fourth ventricle, and then
into the space around the brain via the foramina of Magendie (midline
posteriorly) and Luschka (laterally).
It bathes both the spinal cord and the brain
• Absorption into the dural venous sinuses occurs through the arachnoid
granulations.
• CSF volume is approximately 150 mL, more than three times this
amount is produced in a 24-hour period.

• Functions of continuous flow of CSF

cushions the brain.
maintains a medium in which the brain can function by regulating pH
and electrolytes
carries away waste products.
delivers nutrients
Introduction
• Neuroanesthesia requires a good understanding of
neurophysiology as well as the pathophysiology of raised
intracranial pressure.
• Neuroanaesthetists need to ensure neuro- surgical patients
maintain an adequate cerebral perfusion pressure
intraoperatively.
• To achieve the above,
a balanced anaesthetic technique preventing hypertensive
gushes and optimizing cerebral venous drainage by careful
patient positioning.
Knowledge of the therapeutic options available to decrease
ICP intraoperatively is essential.
Neurosurgical conditions including

Neuro-trauma and other neuro-emergencies such as intracranial hemorrhage.

Vascular neurosurgery includes clipping of aneurysms and performing carotid
endarterectomy (CEA).
Stereotactic neurosurgery, functional neurosurgery, and epilepsy surgery
(partial or total corpus callosotomy – severing part or all of the corpus
callosum to stop or lessen seizure spread and activity, and the surgical
removal of functional, physiological and/or anatomical pieces or divisions of
the brain, called epileptic foci, that are operable and that are causing seizures,
and also the more radical and very, very rare partial or total lobectomy, or even
hemispherectomy – the removal of part or all of one of the lobes, or one of the
cerebral hemispheres of the brain; those two procedures to treat very severe
neurological trauma, such as stab or gunshot wounds to the brain)
Oncological neurosurgery also called neurosurgical oncology; includes
pediatric oncological neurosurgery; treatment of benign and malignant
central and peripheral nervous system cancers and pre-cancerous
lesions in adults and children (glioblastoma multiforme and other
gliomas, brain stem cancer, astrocytoma, pontine glioma,
medulloblastoma, spinal cancer, tumors of the meninges and intracranial
spaces, secondary metastases to the brain, spine, and nerves, and
peripheral nervous system tumors)
Skull base surgery
Spinal neurosurgery
Peripheral nerve surgery
Intracranial Pressure
• is the pressure inside the skull and as a result in
the brain tissue and cerebrospinal fluid (CSF).

• ICP is measured in millimeters of mercury (mmHg) and, at rest,

is normally 5–15 mmHg for a supine adult. (80-180mmH2O)

• The body has various mechanisms by which can keep the ICP
stable, with CSF pressures varying by about 1 mmHg in normal
adults through shifts in production and absorption of CSF.
• Changes in ICP are attributed to volume changes in one or
more of the constituents contained in the cranium.

• CSF pressure has been shown to be influenced by abrupt

changes in intrathoracic pressure during coughing (intra-
abdominal pressure), Valsalva maneuver, and communication
with the vasculature (venous and arterial systems).
Intracranial Pressure
• ICP created by the cerebrospinal fluid (CSF), brain tissue
within the skull & blood.

• How can we measure & monitor the ICP ?

=== by devices in ventricles or subarachnoid space

• If its more than 20mmHg, needs immediate intervention

(Medical Emergency)
 Brain Tissue 80%
+
Cerebral spinal fluid 10%
+
Blood 10%
Intracranial Pressure

• Normal ICP: 5-15 mm Hg / (80-180mmH2O)

Physiological Consideration
• The Monro-Kellie hypothesis states that the cranial compartment
is incompressible and that the volume inside the cranium is fixed
(The skull is a rigid container that cannot expand).

• The cranium and its constituents (blood, CSF, and brain tissue)
create a state of volume equilibrium, such that any increase in
volume of one of the cranial constituents must be compensated by
a decrease in volume of another.

• Therefore, any increase in any of its contents is going to increase

the pressure within the skull.
Intracranial pressure (ICP) is low except in pathologic states.

The Monro–Kellie rule states that

in the setting of a non-distensible cranial vault, the volume

of blood, CSF, and brain tissue must be in equilibrium.

Monro-Kellie hypothesis
• It is applied only to adult (skull is fused). Infants and young
children, suture lines open  allowing for expansion of the
intracranial space in response to increased volume.
• How ICP is affected by CSF, brains blood & tissue to maintain
cerebral perfusion pressure (CPP)?
• How the brain compensate?
Increase volume in one structure leads to other structures
decrease in volume.
by displace the CSF or vasoconstriction decrease the
cerebral blood flow and CPP
Compensatory Mechanisms
Partial collapse of cerebral ventricles

Redistribution of CSF--- mostly subarachnoid space

Auto regulation of blood flow by constriction or dilation of vessels.

• Body compensate to certain extent after that will start giving the
Cushing’s Triad
Alert
As I.C.P. , the brain substances are compressed. A sudden  may
produce an emergency in few minutes. This condition may lead
rapidly to death or result in a negative existence for the patient.
Untreated IICP
• Increase ICP  regional CBF Ischemia

 CPP in area  CO2 and  O2 limits nutrition

to the brain  tissue lactic acid (metabolic by-product)

Lactoacidosis possible impairment of local

autoregulation which again will lead to decrease CBF

• Body tries to compensate; but Pressure continues; body will
activate the vasopressor response increase the systolic
blood pressure (SAP), hoping to increase blood flow to the brain
which leads to swelling edema( Vasogenic)  ICP

• This sequence continues until the autoregulatory mechanism is

inactivated. The blood flow and CPP cannot be maintained in
relationship to the dangerously rising ICP. The CPP  zero & blood
flow  cerebral hernation and death follows immediately.
CPP
• What is Cerebral perfusion pressure(CPP)?
It is the pressure that pushes the blood to the brain…
therefore, it influences the cerebral blood flow (CBF)

• Normal CPP is 60 – 100mmHg.

• When CPP falls too low the brain is not perfused and brain
tissue DIES.

• CPP = MAP – ICP

MAP (Mean Arterial Pressure)

• What's MAP?
is an average blood pressure in an individual during a single
cardiac cycle.
It is considered to be the perfusion pressure seen by organs

in the body.
• Normal MAP = between 70 and 100 mmHg (65 -110 mmHg)

• A MAP in this range indicates that there's enough consistent

pressure in your arteries to deliver blood throughout your body
• MAP is believed that a MAP that is greater than 70 mmHg is
enough to sustain the organs of the average person.

• MAP may be used similarly to Systolic blood pressure in

monitoring and treating for target blood pressure. Both have
been shown advantageous targets for sepsis, trauma, stroke,
intracranial bleed, and hypertensive emergencies.

• If the MAP falls below this number for an appreciable time, vital
organs will not get enough oxygen perfusion, and will become
hypoxic, a condition called ischemia.
Calculating Mean Arterial Pressure
• MAP = 2(DBP) + SBP
3
BP = 102/ 70 Calculate the MAP

• CPP = MAP – ICP

BP = 90/ 42 & ICP = 19 Calculate the CPP

Result: CPP = 39 which is less than normal. What does this

result mean?
Normal causes of ICP

• Sneezing

• Coughing

• Sexual excitement

• Valsalva maneuver
Factors that influence ICP

1. Body temperature.

2. Oxygenation status, especially CO2 & O2 levels.

3. Body position.

4. Arterial and venous pressure.

5. Anything that increases intra-abdominal / thoracic pressure

(vomiting, bearing down)
Oxygenation status, especially CO2 & O2 levels
Cytotoxic edema

• Increase of fluid within the intracellular space, chiefly gray

matter.

• Toxic substances have a negative influence on the cell function.

• Associated with hypoxic or anoxic episode such as acute

hypoventilation on a cardiac arrest.
• ABG's show significant lowering of O2 and increased CO2
(hypercapnia).

• Cerebral cell needs O2 for cell metabolism  absence of

sufficient oxygen at the cellular level  cell metabolism
converts from aerobic to anaerobic metabolism  so, there is
insufficient energy to maintain the adenosine triphosphate
(ATP) dependent sodium pump or active ion transport.
Sodium pump

• Normally, K+ ions in intracellular space and Na+ extracellular

space.

• This balance is maintained by sodium pump  if it is not

functioning properly, more sodium will rush into the intracellular
space, Na+ draws water, causing swelling or edema within the
intracellular space, waste products of cell breakdown such as
lactic acid accumulate, contributing to the rapid deterioration of
cellular function.
• Arteries dilate – increase CO2 ; Limit venous flow = increase
more swelling, increase ICP.

• Displacement brain compress brain stem- respiration and heart

rate.
Etiology of ICP

• Bleeds/stroke
• Tumors
• Head injury
• Hydrocephalous
• Cerebral edema
• Brain abscess
• aneurysms
Signs & Symptoms ---/ MIND CRUSHED

• MIND
Mental status / Earliest
( restless, confused, responding to questions)

Irregular breathing: Cheyne- Stokes / hyperventilation then apnea.

(Late)

Nerve : optic & oculomotor ( double vision, swelling of optic nerve

(Papilledema), unequal pupils, abnormal Doll’s eye ( oculocephalic
reflex)

Decerebrate(worst) or Decorticate Posturing or flaccid

https://www.ncbi.nlm.nih.gov/books/NBK551716/
• TEST FOR THE oculocephalic reflex (doll's eye movement) to
assess cranial nerves III and VI in a comatose patient.
• Absence of this reflex indicates severe brain stem injury from
the midbrain level to the pons.

• https://www.youtube.com/watch?v=OYTvAK6hvsQ
• Decerebrate and Decorticate Posturing
Mind Crushed
• Cushing's triad : Late
------increase SBP- Widening pulse pressure / increase SBP &
decrease DBP
-------- decrease HR, decrease RR ( Abnormal)
Hypertension with
widening pulse pressure

Irregular, shallow
Bradycardia respirations
Vomiting

• Unrelated to food ingestion

• With or without nausea

• May be projectile

• Believed to be r/t pressure on the medulla

Headache

• Early morning headache that gets better throughout the day

• Usually bilateral

• Can be triggered by coughing, bending over or performing the

valsalva maneuver
Papilledema

• May occur with blurred vision

• Occurs when increased pressures impairs outflow of venous

blood thus pressing on the optic nerve
Mind Crushed
• Reflex positive Babinski ( Toes Fanning)

• Unconscious …… late
• Seizures.
• Headache
• Emesis(vomiting) without nausea
• Deterioration of motor / hemiplegia.
Localizing symptoms of ICP

• Specific symptoms that pts. experience are dependent on

where the brain is experiencing pressure.

• A careful neurological exam can accurately locate areas

experiencing pressure.
Frontal Lobe
Personality changes
Decreased mental function-abstract thinking and judgment
Emotional lability
Impaired memory
Expressive aphasia
Contralateral weakness or paralysis
Parietal Lobe

 Contralateral sensory deficits

 Difficulty reading
 Seizures
Occipital Lobe

• Headaches
• Visual field deficits
• Seizures with a visual aura
• Visual hallucinations
Temporal Lobe

• Auditory disturbances
• Psychomotor seizures
• Memory loss
• Auditory hallucinations
Cerebellum

• Ataxia
• Nystagmus
• Difficulty with rapidly alternating movements
• Decreased deep tendon reflexes
• Wide based gait
Brainstem
Hemiparesis
Extraocular nerve palsies
Facial paralysis
Depressed corneal reflex
Hearing loss & tinnitus
Drooling or difficulty swallowing
Vertigo
Vomiting
IICP Management / Prevention & Monitoring
• PRESSURE
Position HOB 30-35 degrees / head midline/ no flexion neck or hip.
Respiration: prevent hypoxia & hypercapnia / monitor ABG O2/
Suction PRN & no more than 15 sec. / mechanical Ventilation –
Paco2 30-35 & keep PEEP law.
Elevated temp. / prevent
damage to hypothalamus, infection, dehydration etc. lead to
increase temperature. So: Monitor temp. if patient is
unconscious : administer antipyretics, cool bath, remove
extra blankets, decrease room temp, cool blankets
PRESSURE ……Cont.

Systems to monitor: Neuro GCS / ventriculostomy / External

ventricular drain.

Straining activities should be Avoided. (vomiting, sneezing,

coughing, Valsalva, keep environment calm & avoid restraints).

Unconscious patient care? Avoid over sedation, check lung

sounds, management of immobile patient (skin break down,
nutrition, renal stones, constipation, range of motion{ROM}, eye
care, GI tubes, blood clots, Rx as conscious).
PRESSURE ……Cont.
Rx:
Barbiturates: decrease brain metabolism & BP so it will lead to
decrease ICP
vasopressors / IVF or
antihypertensive drugs ---- increase BP or decrease BP ----
(SBP more than 90 and less than 150)
Anticonvulsants,
hyperosmotic drugs.
PRESSURE ……Cont.
• Edema management: to dehydrate the brain in a very careful
way because of BP & renal function.

Mannitol: it is concentrated sugar, draws water that is pooling

in the brain into blood. Fluid filtered through glomerulus; Not
reabsorbed in renal tubules which leads to water removal &
decrease Na+ & chloride

do not give for anuria or cerebral hemorrhage.

• Risk of Mannitol

Measurement of glomerular filtration rate before administration

of mannitol to prevent the risk of

1. Fluid volume overload which will lead to heart failure &

pulmonary edema ( loop diuretics & corticosteroids.)

2. Depletion- thirst & dry mouth ( dehydration= renal function,

urine output & electrolytes