• Physiology
• Waveforms
• Monitoring
Physiology
Vintracranial vault=Vbrain+Vblood +Vcsf
• “compliance reflects the
ability of the intracranial
system to compensate for
increases in volume
without subsequent
increases in ICP. When
compliance is decreased,
even small increases in
intracranial volume
result in large increases
in ICP.”
Normal ICP
• It is difficult to establish a universal “normal
value” for ICP as it depends on age, body posture
and clinical conditions.
• The upper limit of normal ICP – 15 mm Hg
(5 – 10 mm Hg)
• Physiologic increase – Coughing, sneezing – 30-50
mm Hg
ICP waveforms
ICP monitoring waveforms
Flow of 3 upstrokes in one wave.
• clogged / kinked
• Patient expired
↑⁄↓ amplitude
• Increasing CSF volume
(or decreased)
• If a large volume of CSF
is drained off, the
waveform will decrease
in amplitude.
• Missing bone flap
Prominent P1 wave
• Hyperventilation
Rounded ICP waveform
Nils Lundberg
Lundberg A wave
Lundberg A waves
• Increases of ICP sustained for several minutes and
then return spontaneously to baseline, which is
slightly higher than the preceding one.
• Results from ↑ cerebrovascular volume due to
vasodilatation (Lundberg)
• Results from normal compensatory response to
decreases in CPP. Hence give vasopressors.
(Rosner) – But may enhance lesion size & edema
4 phases:
1. Drift phase : ↓ CPP → vasodilatation
2. Plateau phase : Vasodilatation → ↑ ICP
3. Ischemic response phase : ↓ CPP → Cerebral
ischemia → Brainstem vasomotor centres →
Cushing response
4. Resolution phase : Cushing response →
Restores CPP
Lundberg B wave
Lundberg B waves
• Short elevations of modest nature (10 – 20 mm
Hg)
• 0.5 – 2 Hz
• Relate to vasodilatation secondary to respiratory
fluctuations in PaCO2
• Seen in ventilated patients
• Secondary to intracranial vasomotor waves,
causing variations in CBF
• Reflects ↑ ICP in a qualitative manner
Lundberg C waves
Lundberg C wave
Lundberg C waves
• More rapid sinusoidal fluctuation (0.1 Hz)
• Corresponds to Traube-Hering-Meyer
fluctuations in arterial pressure brought about
by oscillations in baroreceptor and
chemoreceptor reflex control systems
• Sometimes seen in normal ICP waveform
• High amplitude – pre-terminal, seen on top of
A waves
ICP monitoring
Why look at ICP waveform analysis?