EVALUATION OF A PATIENT WITH INCREASED INTRACRANIAL PRESSURE Understanding its Signs and Dreadful Effects Dra Di!

ina " Hernande#$ FPNA Se%te&'er ($ )*+( *if you will not treat the cause of IICP/ manage IICP, it can lead to coma. T,e Anat-&ic As%ects -f ICP

a closed #ault, where the meningeal layer continues into the spine

1entorium: separates the corte from the infratentorial structures $cerebellum and the brainstem' 1entorial notch: opening) #ery important in relation to herniation Fal Cerebri: does not completely di#ide the cerebral hemispheres anteriorly Tent-riu& Cere'elli

Cerebrospinal Fluid review of the CSF flow CSF production: produced by the choroid ple us in the lateral !rd and "th #entricles $%&& ml/day' CSF #olume in the #entricular space: (! ml) "*+ ml is reabsorbed. CSF also bathes the lumbar and subarachnoid space ,nidirectional If there is a bloc-ade in the subarachnoid space . IICP $first intra#entricular pressure then intracranial pressure' S-ull and the /ertebral column For as long as the sutures are fused $children:known skull sutures will fuse by 2 y/o; 25 y/o: all the basilar sutures will close'. no more gi#ing way 0 If there is something happening in the brain before the sutures close, there will be an enlarging head circumference and the sutures will not close, therefore there is widening of sutures. 1he fontanels which may still be open, will be bulging. Children with compensation in the s-ull will not ha#e signs and symptoms of IICP Cerebral blood flow 20% of cardiac out ut or !50 "l/ "in2 1he brain recei#es constant blood supply re#ardless of what is happening in the body. $1he brain is 3selfish3.' In cases of hy ovole"ia or hy o$e"ia, the brain still draws blood . until compensation fails: loss of consciousness. *4thers: 5ura mater #ery durable) does not yield to increased #olume if there is traction, you may e perience headache FINALS 1 MEDISINA BATCH 2016 mdcaultado

li-e a 3tent3 increase in pressure supratentorially or infratentorially . tentorium will constrict or press on the brain stem *Cli#us: posterior to it:basilar artery) where the pons sits

T,e Tent-riu& and t,e Ven-us Sinuses

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*5o not forget the #eins6 1he #enous sinuses which lie in between the dural reflections are the main draining structures of the brain. 1he blood must be drained . goes to the heart for recirculation. #eins can cause IICP and possible instantaneous death $unli-e arterial, which ta-es time' if compressed . IICP

Relati-ns,i% -f t,e tent-riu& /it, t,e 'rainste&

*there is a tearing of the meningeal artery . ra idly growing hematoma Its shape is dependent on the sutures $remember: 7l%ns li-e8. l%ntiform shape . %pidural 0' Patient with epidural hematoma: lucid intervals$cycle of sleeping and wa-ing, where the patient is awa-e shorter and shorter and asleep longer and longer) can happen few hours after the in9ury' . e#entually will lead to co"a T,e T,ree Intracranial C-&%-nents 1. Brain 1350g (fema e!" # 1500g (ma e!" ($: It:s not the weight of the brain that counts:p' *only around %&g when suspended in CSF

2. CSF %o &me
'5#1(0 mL a) an* one )ime function: buoyancy effects for protection and support

3. B oo+ %o &me, '5# 150 mL

Cere'ral 0l--d fl-/ 20- of C./ or '50 mL0min goe! )o )1e 2rain cere'ral aut-1regulati-n *capacity to regulate and maintain a constant cerebral blood supply/flow. *Stro-e: degenerati#e process: atherosclerosis . rigid blood #essels . constriction a2i i)* )o main)ain 3ere2ra 4erf&!ion 5i)1in !)ri3) * +e)ermine+ imi)!6 3om4en!a)or* 31ange in C78 in re!4on!e )o %aria)ion! in %a!3& ar 4re!!&re! e#en with low systemic blood pressure, the brain will still mdcaultado Page ) of .

E%idural ,e&at-&a

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get +%& m;/min $the brain is a 3spoiled brat3' only with prolonged hypotension will the patient lose consciousness .coma . death CBF 9 CAP # :7P0C78 51ere CAP 9 3aro)i+ ar)er* 4re!!&re :7P 9 ;&g& ar %eno&! 4re!!&re C78 9 3ere2ro#%a!3& ar re!i!)an3e (m*ogeni3/ a&)onomi3 an+ me)a2o i3 me31ani!m!" <e of metabolic mechanism: hypercarbia or hypo ia e of autonomic: <= or epinephrine Cere'ral Perfusi-n Pressure in+i3a)e! )1e effe3)i%e 4re!!&re 1ea+ for 3ere2ra 3ir3& a)ion CPP 9 SAP # ICP =1ere, SAP 9 !*!)emi3 ar)eria 4re!!&re (100mmHg" ICP 9 in)ra3rania 4re!!&re (15#(5 mL 12. or 0# 135 mL CSF" CPP 9 BP > ICP < >?P $mean arterial pressure'@( diastolic AP B S AP/! *IICP: S?P must also increase in order to maintain a normal CPP *?n increase AP in a patient who has a brain pathology indicates that there is an increasing ICP. &o not lower the '() treat the **C(+ "-nr-12ellie D-ctrine an* in3rea!e in %o &me of an* of )1e )1ree in)ra3rania 3om4onen)! m&!) 2e a) )1e e?4en!e of )1e o)1er )5o *when the brain parenchyma increases its #olume d/t tumor, hemorrhage or an abscess .compensation: CSF #olume and blood #olume *hydrocephalus $increase in CSF' .compensation of brain and cerebral blood flow of )1e 3/ 2rain i! )1e least c-&%ressi'le intracranial c-&%liance refer! )o 31ange in ICP for a gi%en 31ange in in)ra3rania %o &me ,therefore, if there is an increase in #olume there will always be compensation . no sign of IICP) but if there is intolerance and no compensation . signs of IICP Intracranial V-lu&e1Pressure Relati-ns,i%s c-&%liance i! a mea!&re of )1e in)ra3rania 3om4ar)men)! tolerance )o %o &me)ri3 a++i)ion! (in other words, the compartmentCs ability to DstretchC to accommodate an increase in #olume' elastance, intolerance of )1e !*!)em )o a++e+ %o &me only when this compensatory mechanism is e hausted will the ICP increase -an#fitt e$ eri"ent first demonstration of this phenomenon normal ICP: .5/05 ""1# *5r. ;angfitt placed an e tradural bulb $initially', then intradural bulb) in the e periment, he increased the #olume by E m;/min . an additional E ml has drastically increased the pressure $at * ml': *ntracranial co" liance $the ability to accommodate the additional #olume' . no more compensation . collapse of #essels . the brain parenchyma is increasing . headache and other symptoms of IICP

I want you to remember this cur#e. Ghen you ha#e patients with brain tumor $meningitis or stro-e' this is the graph that you will tell the patients so that they will understand you. H

W,at Ha%%ens in Increased Intracranial Pressure3

*FPC4( during C4P5 and pneumonia *uterine atony: lose muscle tone . blood loss T,e Intracranial Pressure Wa!es T4%e 0, nor"al wa#es # r1*)1mi3 %aria)ion re a)e+ )o %ario&! )*4e! of 4erio+i3 2rea)1ing 5i)1 a fre@&en3* of 1#20min *referable to our normal breathing T4%e C # r1*)1mi3 %aria)ion! re a)e+ )o Trau'e1Herring1"a4er /a!es of !*!)emi3 BP (60min" T4%e A # %lateau $*sudden increase . le#eling. fall' /a!es +&e )o e e%a)ion of ICP a!)ing 5#20 min&)e!6 re!) e!!ne!!/ im4aire+ 3on!3io&!ne!!/ rigi+i)* of im2!/ )oni3#3 oni3 mo%emen)! * seen in IICP *fall: d/t compensation Cardinal Signs -f 0rainste& D4sfuncti-n 31ange in 2e1a%ior an+ 4er!ona i)* +e3rea!e+ e%e of 3on!3io&!ne!! 3oma re!4ira)or* 31ange!

Cardinal effects -f increased ICP FINALS 1 MEDISINA BATCH 2016 mdcaultado Page ( of .

Arain abscess: loo- at the history $Chronic otitis media' I1< can lead to intracranial hematoma $sudden rupture of #essels' Arain edema: classically in metabolic problems especially in drowning $that is how they die' *CSF problems: obstruction in the flow 1A,subarachnoid hemorrhage: #ery notorious >alabsorption2 e . bloc-ade $aJueductal stenosis' 4#erproduction: choroid ple us papilloma *Alood #olume Inc in pC4( d/t #asodilatation Signs and S4&%t-&s -f Increased ICP 4rogre!!i%e 1ea+a31e 25or!e in )1e morning *because when you sleep your breathing becomes bradypneic . FpC4( .#asodilatation 25i)1 )ra3)ion 31ara3)er *worsens when there is an increase in pressure $e . patient bends, coughs, sneeKes, etc.' 2tachypnea due to increased pC4( e?4 o!i%e 4ro;e3)i e %omi)ing <no retching or nausea) sudden <1his happens when there is failure in compliance. mass in the frontotemporal area. presses on the uncus: uncal herniation Cereberal mass: tonsil will herniate in the foramen magnum $1onsilar herniation or Foraminal herniation' >ass in the frontal lobe: Cingulate gyrus herniation Subfal ial herniation 1umor in the brainstem, thalamus, diencephalon or se#ere pressure in the entire brain: Central 1ranstentorial Ierniation S4ste&ic Effects -f Increased ICP C&!1ingA! )ria+ re!4ira)or* 31ange! 2ra+*3ar+ia 1*4er)en!ion, * I1< is a late sign of IICP *classically seen in increase intra#entricular pressure, also in IICP *hypo#olemia.hypotension and tachycardia Ne&rogeni3 4& monar* e+ema not pulmonary edema due to autonomic problems 2 adult respiratory distress syndrome $23&S' Causes -f Increased ICP +i4 o4ia d/t bilateral or unilateral *th ner#e palsy $longest intracranial course' 1he diplopia will be worse when the patient loo-s out or laterally. 3Ghen does the shadow de#iateL Is it when loo-ing to the right or when loo-ing to the leftL3 4a4i e+ema *loo- at the fundus, #essels and the margin. If the margin is not clear/ not distinct: $B' hemorrhage: Cho-ed disc . increase in 24 ratio 52/6:.' . the #ein becomes big $e (:" or E:"' ?/ ratio: earliest sign of papilledema fo3a ne&ro ogi3 +efi3i)! 6uic7 Assess&ent -f C-&at-se Patients *;oo- at the pupil. ;oo- if there is anisocoria Swinging flashlight test: consensual light refle *=ye position test *Posture *Mespiration *uncal herniation 2 ipsilateral eye is abducted, ipsilateral ptosis, and anisocaria

5Arain parenchyma Arain tumor: glioblastoma multiforme or metatastic brain tumor FINALS 1 MEDISINA BATCH 2016 mdcaultado Page 8 of .

Res%irat-r4 C,anges in Increased ICP

due to in9uries to the pons and medulla ischemia due to blood #essel or artery compression $uncus may compresses the artery'

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0edside "anage&ent -f Increased ICP e e%a)e )1e 1ea+ 30B 1ea+ m&!) a 5a*! 2e in ne&)ra 4o!i)ion en!&re 4a)en) air5a* BP moni)oring an+ managemen) # remem2er )1a) HTN i! a a)e manife!)a)ionC Do no) a o5 )1e 4a)ien) )o !)rainC A+%i!e )1e 4a)ien) no) )o ea) g&a%a/ 2anana/ e)3C +o no) a o5 4a)ien) )o !)rain 3orre3) fe%er Su&&ar4: T1e rigid s7ull an+ &n*ie +ing dura &ater are )1e main anatomical structures 51en +ea ing 5i)1 in3rea!e+ ICPC In infan)! an+ *o&ng 31i +ren/ 51en )1e anteri-r f-ntanel i! !)i o4en/ in3rea!e+ ICP i! no) rea+i * a44aren) *cat:s cry: #ery shrill H sign of IICP *fontanel: if you feel pulsations: o-6 0 Aut if it is rigid: $fatal .angeeeel na' =1en )1e in)ra3rania %o &me e?3ee+! )1e c-&%ensat-r4 &ec,anis&s of )1e in)ra3rania 3om4onen)!/ !ign! an+ !*m4)om! of in3rea!e+ ICP are manife!)e+C <5o not strain =1en )1i! !i)&a)ion i! no) re3ogniDe+ or manage+ 4ro4er */ )1e )1e +e#3om4en!a)e+ 2rain no5 ,erniates in)o o4ening! in )1e in)ra3rania %a& ) )1e cingulate g4rus subfal ially )1e uncus in)o )1e tentorial notch )1e cere'ellar t-nsils in)o )1e foramen magnum D&ring 1ernia)ion/ 2 oo+ %e!!e ! are 3om4re!!e+ a!i+e from )1e 2rain!)emC En e!! )1e 4a)1o og* i! !o ma!!i%e (a! in g&n!1o) 5o&n+ an+ !e%ere 3r&!1ing in;&rie! )o )1e 2rain/ ma!!i%e in)ra3rania 1emorr1age 5i)1 !&2ara31noi+ an+ 5i)1 %en)ri3& ar e?)en!ion/ m& )i4 e 2rain )&mor! 5i)1 e+ema/ or !e%ere me)a2o i3 3om4romi!e"/ there is always time to recogniKe increased ICP for a44ro4ria)e managemen)C Be+!i+e !)ra)egie! 3an re+&3e ICP e%en 5i)1o&) )1e ai+ of me+i3ine!C

Ta7e ,-&e &essage: 2NOWLED;E SAVES LIVES<

A man 51o +oe!nF) !4en+ )ime 5i)1 1i! fami */ i! ne%er a rea manC #Don 7i)o Cor eone

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