Intracranial Pressure.ppt

PresentationandManagementofRaisedIntracranialPressure AmroAl HabibMD FRCSC MPHNeurosurgery 1 428surgeryteam Doneby 428surgeryteam Objectives TolearnwhatarethebasicsofICP WhatthingsthatformICPinsidethebrain HowyoulowerICP HowyoucanidentifyraisedICP ICP Intra CranialPressure 2 428surgeryteam Basics ComponentsofcraniumNormalcomponents Brain1400mlCSF75 100mlBlood75mlAbnormalcomponents TumorshematomaMonro KellieDoctrineThesecontentsareincompressibleTherefore changeinvolumeofthebrainisassociatedwithchangeinCSForbloodvolume 3 428surgeryteam Pressure Volume Increaseinvolumeinonecompartmentleadstochangeinvolumeintheotherones E g braintumor CSFvolume thenbloodvolume Forhowlongcouldthisgoon actually itdiffersfromonepersontoanother e g ifasmallbenignbraintumorstartsgrowingandthenreachesaphaseofgrowingthatthebraincan ttolerateoraccommodate butsomebrainscan 4 428surgeryteam v imp Asmuchweincreasethevolume thepressurewillincrease First alittleincreaseinpressurewithalittleincreaseinvolume Then withthesameincreaseinvolumetherewasahugeincreaseinpressure anincreaseinthevolumealittlebitcantakethecurveover Thisisthecharacteristicsofbrain withinafewminuteseverythingcanchange Pt willcamewithheadacheandvomitingandwithinasmallincreaseinthevolumethepressurewasnottoleratedandhehadtogotoemergencycraniotomy RaisedICPLaurenceTDunn JneurolNeurosurgPsychiatry 2002 5 428surgeryteam CansomebodywalkaroundwitharaisedICP Yes mostpts withbraintumorstheycamewalkingtothehospital 6 428surgeryteam RaisedICPandbrainshift CingulateherniationUncalherniationCentralherniationOutsideherniationTonsillarherniation Herniationsinthebrain thebrainisactuallyundersomuchpressureanditwillgotoleastresistancepartinthebrain 7 428surgeryteam Fromthepreviousslide Uncalherniation uncusisthemostmedialpartofthetemporallobeso it sthepartthatisgoingtoherniatemostcommonclinicallyseenCentralherniation ahematomaormasscompressingtheupperpart itpushesthewholebraindownthroughthetentorialopening Tonsillarherniation ifthereismassiveincreaseintheICPespeciallythataroundthecerebellum thetonsilwillcomedowntotheforamenmagnumandthenitcompressesthelowermedullawherethecentreofrespirationisthereandtheptwillstopbreathing Thistypeisfatal 8 ICPwaveform It sthesameastheheartwaveformanditgivesthebrainpulsationandthispulsationiswhatformsyourICP 9 428surgeryteam NormalICP RaisedICPLaurenceTDunn JneurolNeurosurgPsychiatry 2002 10 428surgeryteam CerebralautoregulationAbilityofcerebralvesselstomaintaincerebralperfusionwithinstrictlydeterminedlimitsRiseinSBP ConstrictionofcerebralarteriesLowSBP cerebralvesselsdilatetoaccommodateLossofautoreglation ChangeincerebralbloodflowwiththechangeinBP 11 428surgeryteam CerebralAutoregulation RaisedICPLaurenceTDunn JneurolNeurosurgPsychiatry 2002 12 428surgeryteam BPandCBF IfICPgoesup howdoesthebraingetperfusion ProcessofautoregulationCPP MAP ICP v imp If MAP 85mmHgICP 15mmHgCPP CPP CerebralPerfusionPressureMAP MeanArterialPressure 13 428surgeryteam CPP50 140mmHg 14 428surgeryteam 20yearoldman Hadcaraccident MVC asunrestraineddriver HepresentedwithBP75 30 HR125bpm Unconscious withrighthemiplegia Whatisgoingon Anotherpossibilityisthepatienthashematomainthebrainthat swhyheiswithhemiplegiaandheisbleedingsomewhereinthebodyandbecauseofthatheishypotensiveandunconsciousandhehashighHRHowwedealwithhimintheemergency ABC fluid C Ttoknowwhyheisunconscious 15 428surgeryteam PossibleCauses VITAMENDisvitaminDdeficiencyisapossiblecauseofraisedICP NO itanabbreviationofVascular Infection Trauma Autoimmune Metabolic Endocrine Neoplastic Drugs Other 16 428surgeryteam ClinicalPresentationofraisedICP Headache vomiting papilloedemaV impHeadacheEarlymorningThrobbing Bursting sneezing coughingPapilleodemaReliablebutmaytakeseveraldays happenedonlywithchronicproblemslikewithgrowingbraintumor AssociatedfundalhgeindicatesacuteandsevereriseinICP 17 428surgeryteam 18 428surgeryteam GCS veryimptoassestheseverityofcoma DecreasedLevelofConsciousness It sacomascorenotaweaknessscore Thepatienttakes6evenheiswithhemiplagia 19 428surgeryteam WhenitcomestoheadinjurythereaclassificationofGCS MildGCS 13 15ModerateGCS 9 12SevereGCS 3 8ThelowestnumberinGCSis3andthehighestnumberis15 20 428surgeryteam Neurological PupillarydilationHemiplegiaCranialnervedeficit 21 428surgeryteam missinglink ucsf edu HerniationGross jpg 22 428surgeryteam 23 428surgeryteam Ifthereisamasscompressingthe3rdnerveSo ipsilateralpupildilationandcompressiononthebrainstemwillgiveyoucontralateralhemiplasia weakness missinglink ucsf edu TentorialNotchBlum jpg 24 428surgeryteam Trans tentorialherniation Ipsilateraldilatedpupil Contra lateralweakness 25 428surgeryteam missinglink ucsf edu tonsillar 20hern 2a jpg Tonsillarherniation 26 428surgeryteam Falselocalization Kernohan snotch Simply whenthereisahugegrowingrightsidehematomaitwillpushthewholebrainstemtotheoppositesideandthatmaycauseipsilateralweaknessandcontra lateraldilatedpupil 27 428surgeryteam Systemic RaisedBP recall CPP MAP ICP Respiratorychange Cheyne Stokesbreathing Oscillatingperiodsofapnea tachypneaRespiratorycenterscompromise 28 428surgeryteam RaisedICPininfantsresultsin WidenedsuturesIncreasedHeadcircumferenceDilatedheadveins Sunset eyes hiseyesalwayslookingdown 29 428surgeryteam 30 428surgeryteam Investigations URGENTCTheadNOLumbarPunctureuntilyoudoatleasttheCT 31 428surgeryteam WhatisthetreatmentofhighICP Generalmeasures Headelevation 30degrees NoneckcompressionMannitolforpatientswhohavedecreasedLOC orFurosemide Steroids Dexamethazone fortumorsHyperventilation controlledtoPCO235 40mmHgSedation musclerelaxantsHypothermiaBarbiturates term