INTRACRANIAL PRESSURE

It

is the pressure of the subarachnoidal fluid, which fills the space between the skull and the brain. The normal ICP is 10 to 20 mmHg or 5 to 15

DEFINITION
intracranial pressure is a rise in the pressure inside the skull that can result from or cause brain injury. It is the result of the amount of brain tissue, intracranial blood volume, and cerebrospinal fluid (CSF) within the skull at any time.
Increased

CAUSES

Increased intracranial pressure can be due to a rise in cerebrospinal fluid pressure. It can also be due to increased pressure within the brain matter caused by a mass (such as a tumor), bleeding into the brain or fluid around the brain, or swelling within the brain matter itself.

CONDITIONS CAUSES ICP

Aneurysm rupture and subarachnoid hemorrhage Brain tumor Encephalitis Head injury Hydrocephalus (increased fluid around the brain) Hypertensive brain hemorrhage Intraventricular hemorrhage Meningitis Subdural hematoma Status epilepticus Stroke

SYMPTOMS
INFANTS Drowsiness Separated sutures on the skull Bulging of the soft spot on top of the head (bulging fontanelle) Vomiting

OLDER CHILDREN AND ADULT: Behavior changes Decreased consciousness Headache Lethargy Neurological symptoms, including weakness, numbness, eye movement problems, and double vision Seizures Vomiting

PATHOPHYSIOLOGY
The only three things in the skull are brain tissue, blood and CSF. If any abnormality (e.g. edema from trauma, brain tumor) occurs in the adult skull (i.e. closed cavity); there is no room for expansion, which results in neurologic deficits because of the increased pressure in the closed cavity. The body compensates for this increased pressure or decompensates.

Compensatory mechanisms for maintaining ICP within normal limits include: -Increased CSF absorption -Shunting of blood to the spinal subarachnoid space -Decrease CSF production

Failure of these compensatory mechanisms results in decompensation with the following sequence of events: -Decreased cerebral blood flow with inadequate perfusion -Increased partial pressure of carbon dioxide and decreased partial pressure of oxygen, leading to hypoxia -Vasodilation and cerebral edema -Further increases in ICP

RISK FACTORS
Head injury Stroke Inflammatory lesions Brain tumor Intracranial surgery

DIAGNOSTIC EXAM

 CEREBRAL ANGIOGRAPHY

CT

SCAN MRI PET SCAN SPINAL TAP OR LUMBAR PUNCTURE

COMPLICATIONS
BRAINSTEM

HERNIATION DIABETES INSIPIDUS SIADH (syndrome of inappropriate diuretic hormone)

HYPEROSMOLAR THERAPY
Mannitol is the most commonly used hyperosmolar agent for the treatment of intracranial hypertension. More recently, hypertonic saline also has been used in this circumstance. A few studies have compared the relative effectiveness of these two hyperosmotic agents, but more work is needed.

HEAVY SEDATION AND PARALYSIS

A commonly

used regimen is morphine and lorazepam for analgesia/sedation and cisatracurium or vecuronium as a muscle relaxant, with the dose titrated by twitch response to stimulation.

HYPERVENTILATION

Hyperventilation decreases PaCO2, which can induce constriction of cerebral arteries by alkalinizing the CSF. The resulting reduction in cerebral blood volume decreases ICP. Hyperventilation has limited use in the management of intracranial hypertension, however, because this effect on ICP is time limited, and because hyperventilation may produce a sufficient decrease in CBF to induce ischemia.

BARBITURATE COMA
Barbiturate

coma should only be considered for patients with refractory intracranial hypertension because of the serious complications associated with high-dose barbiturates, and because the neurologic examination becomes unavailable for several days. Pentobarbital is given in a loading dose of 10 mg/kg body weight followed by 5 mg/kg body weight each hour for 3 doses.

HYPOTHERMIA

Although a multicenter randomized clinical trial of moderate hypothermia in severe TBI did not show a beneficial effect on neurologic outcome, it was noted that fewer patients randomized to moderate hypothermia had intracranial hypertension.

STEROIDS
Steroids

commonly are used for primary and metastastic brain tumors, to decrease vasogenic cerebral edema. Focal neurologic signs and decreased mental status owing to surrounding edema typically begin to improve within hours

SURGICAL MANAGEMENT

RESSECTION OF MASS LESIONS

Intracranial masses producing elevated ICP should be removed when possible. Acute epidural and subdural hematomas are a hyperacute surgical emergency, especially epidural hematoma because the bleeding is under arterial pressure. Brain abscess must be drained, and pneumocephalus must be evacuated if it is under sufficient tension to increase ICP.

CEREBROSPINAL FLUID DRAINAGE

CSF drainage lowers ICP immediately by reducing intracranial volume and more long-term by allowing edema fluid to drain into the ventricular system. Drainage of even a small volume of CSF can lower ICP significantly, especially when intracranial compliance is reduced by injury.

DECOMPRESSIVE CRANIECTOMY

The surgical removal of part of the calvaria to create a window in the cranial vault is the most radical intervention for intracranial hypertension, negating the Monro-Kellie doctrine of fixed intracranial volume and allowing for herniation of swollen brain through the bone window to relieve pressure. Decompressive craniectomy has been used to treat uncontrolled intracranial hypertension of various origins, including cerebral infarction trauma, subarachnoid hemorrhage, and spontaneous

NURSING MANAGEMENT

NURSING MANAGEMENT
Monitor vital signs closely. Maintain patent airway. Administer medications as ordered. Elevate head of bed (30). Administer hypertonic I.V. solutions as ordered. Protect patient from injury should seizures occur. Maintain normal body temperature.

PATIENT EDUCATION

Family members of patients who return home following injury to the head should be instructed to return the patient to the hospital if any of the following problems occur.

Fever greater than 100F. Pulse less than 50 beats per minute. Vomiting. Slurred speech. Dizziness. Blurred or double vision. Unequal pupil size. Blood or fluid discharge from ears or nose. Increased sleepiness. Inability to move extremities. Convulsions. Unconsciousness