Surg351 presentation and management of raised intracranial pressure
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Transcript of Surg351 presentation and management of raised intracranial pressure
Presentation & Management of
Raised Intracranial Pressure
ByBy
ZainZain AlabedeenAlabedeen B. B. JamjoomJamjoom, M.D., M.D.
Professor of NeurosurgeryProfessor of Neurosurgery
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Normal Intracranial Pressure
�� Normal ICP ~10 mmHg Normal ICP ~10 mmHg (supine at the level of the foramen of (supine at the level of the foramen of MonroMonro))
�� Pulsatile Pulsatile
�� Fluctuates with the respirationFluctuates with the respiration
�� ICP >20 mmHg is definitely pathologicalICP >20 mmHg is definitely pathological
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Normal ICP Waveformt (sec)
ICP
ECG
Resp.
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Cerebral Blood Flow (CBF)
�� Flow = Flow =
�� CBF = CBF =
�� CPPCPP = Mean = Mean systsyst. art. BP . art. BP -- Mean ICPMean ICP
Cerebral perfusion pressure (CPP)Cerebral perfusion pressure (CPP)
Cerebral vascular resistance (CVR)Cerebral vascular resistance (CVR)
PressurePressure
Resistance Resistance
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Intracranial Cavity
�� Its volume is virtually constant. Its volume is virtually constant.
�� It is filled to capacity with fluids & solid It is filled to capacity with fluids & solid
material that are nonmaterial that are non--compressible. compressible.
�� ThereforeTherefore: :
Increase in one constituent or an Increase in one constituent or an
expanding mass within the intracranial expanding mass within the intracranial
space results in raised ICP space results in raised ICP ((MonroMonro--Kellie Kellie
Doctrine)Doctrine). .
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Intracranial Cavity
Content
�� Brain:Brain:
–– NeuronesNeurones 500 500 -- 700 ml700 ml
–– GliaGlia 700 700 -- 900 ml900 ml
–– ExtracellularExtracellular fluid 100 fluid 100 -- 150 ml150 ml
�� Blood: Blood: 100 100 -- 150 ml150 ml
�� Cerebrospinal fluid: Cerebrospinal fluid: 100 100 -- 150 ml150 ml
Constituents are nonConstituents are non--compressible compressible
but partially displaceablebut partially displaceable
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ICP/Volume Curve
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Intracranial Cavity
3 compartments
�� 2 2 supratentorialsupratentorial
spaces, separated spaces, separated
by the by the falxfalx cerebricerebri, ,
andand
�� 1 infratentorial1 infratentorial
space, separated space, separated
from from supratentorialsupratentorial
spaces by the spaces by the
tentoriumtentorium..
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Intracranial Mass
Shifts
(Cerebral
Herniations)
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Transtentorial (Uncal) Herniation
Bilateral
Unilateral
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The Tentorial
Hiatus
Oculomotor nerve
Posterior cerebral artery
Cerebral peduncle
Reticular formation
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Transtentorial Herniation
�� Compression of 3Compression of 3rdrdCN: CN:
–– Dilatation of Dilatation of ipsilateralipsilateral pupil.pupil.
�� Compression of the midCompression of the mid--brain:brain:–– Impairment of consciousness.Impairment of consciousness.
–– HemiparesisHemiparesis (usually (usually contralateralcontralateral, but , but occasionally occasionally ipsilateralipsilateral).).
–– Hypertension + Hypertension + BradycardiaBradycardia (Cushing response).(Cushing response).
–– Respiratory failure.Respiratory failure.
�� Compression of post. cerebral artery:Compression of post. cerebral artery:
–– Infarction of occipital lobeInfarction of occipital lobe
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Syndrome
of Unilateral
Uncal
Herniation
Early Phase
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Syndrome
of
Unilateral
Uncal
Herniation
Late Phase
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A main cause of uncal herniation
is Extradural Hematoma
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Clinical Symptoms & Signs of
Raised ICP
�� HeadacheHeadache
�� Nausea and vomitingNausea and vomiting
�� PapilledemaPapilledema
�� Impairment of consciousnessImpairment of consciousness
�� 66ththcranial nerve palsy: False cranial nerve palsy: False
localizing signlocalizing sign
�� Impaired level of consciousnessImpaired level of consciousness
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Signs of Raised ICP
Normal Papilledema
Papilledema
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Signs of Raised ICP
Abducent Nerve Palsy
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Clinical Symptoms & Signs of
Raised ICP in Infants
�� Large head (Large head (MacrocephalyMacrocephaly))
�� Tense & enlarged anterior Tense & enlarged anterior
fontanelfontanel
�� Separated skull suturesSeparated skull sutures
�� Prominent scalp veinsProminent scalp veins
�� ““Sun setSun set”” of eyesof eyes
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Macrocephaly
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Investigations
�� Method of choice:Method of choice:
URGENTURGENT brain CT scan.brain CT scan.
�� Skull XSkull X--rays:rays:
–– Separated suturesSeparated sutures
–– Silver beaten appearanceSilver beaten appearance
�� Lumbar puncture isLumbar puncture is
CONTRAINDICATEDCONTRAINDICATED..
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Separated Skull Sutures
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Silver Beaten Appearance
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Causes of Increased ICP
�� Increased volume of normal intracranial Increased volume of normal intracranial
constituents:constituents:
–– Brain: Cerebral edema.Brain: Cerebral edema.
–– Cerebrospinal fluid: Hydrocephalus.Cerebrospinal fluid: Hydrocephalus.
–– Blood volume: Vasodilatation 2Blood volume: Vasodilatation 2ooto COto CO22
�� A spaceA space--occupying lesion:occupying lesion:
-- TumorTumor -- Hematoma Hematoma
-- AbscessAbscess -- CystCyst
�� Idiopathic: Idiopathic:
–– PseudotumorPseudotumor cerebricerebri
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Cerebral Edema
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Hydrocephalus
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Intracranial
Tumor
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Intracranial Tumors
�� Intrinsic: Intrinsic:
–– Arise from brain tissueArise from brain tissue
–– Majority are Majority are gliomasgliomas (Grades I to IV)(Grades I to IV)
�� Extrinsic: Extrinsic:
–– Arise from intracranial tissue other than brainArise from intracranial tissue other than brain
–– Include: Meningioma, Pituitary adenoma, Include: Meningioma, Pituitary adenoma, SchwannomaSchwannoma
�� Location:Location:
–– Adults: mainly Adults: mainly supratentorialsupratentorial
–– Children: mainly Children: mainly intratentorialintratentorial
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Brain Abcsess
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Brain Abscess
�� Develop as a result of a localized Develop as a result of a localized bacterial bacterial cerebritiscerebritis followed by necrosis followed by necrosis and encapsulation.and encapsulation.
�� Mechanisms:Mechanisms:
–– HematogenousHematogenous
–– Extension from Extension from neighbouringneighbouring structuresstructures
–– Penetrating injuriesPenetrating injuries
�� Symptoms of infection may be absent in Symptoms of infection may be absent in 50% of cases 50% of cases
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Treatment of Raised ICP
�� General measures for reducing General measures for reducing
raised ICPraised ICP
�� Definitive treatment:Definitive treatment:
Removal of the causeRemoval of the cause
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General Measures to Reduce Raised ICP
�� Head elevation 30Head elevation 30ooup in neutral position.up in neutral position.
�� Diuretics:Diuretics:
–– MannitolMannitol : 20% 1g/kg iv single dose or : 20% 1g/kg iv single dose or 0.250.25--0.5g/kg Q8h0.5g/kg Q8h
–– FurosemideFurosemide : 1mg/kg iv : 1mg/kg iv sinlglesinlgle dose or dose or 0.250.25--.05mg/kg Q8h.05mg/kg Q8h
�� NormovolemiaNormovolemia: IV infusion of : IV infusion of cristalloidcristalloid
�� Controlled hyperventilation:Controlled hyperventilation:
–– pCO2 reduction to 30 pCO2 reduction to 30 -- 35 mmHg.35 mmHg.
�� Sedation & Muscle relaxation.Sedation & Muscle relaxation.
�� CSF withdrawal. CSF withdrawal. No lumbar punctureNo lumbar puncture
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Ventriculo-peritoneal Shunt
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Excision of Intracranial Tumor
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Drainage of Brain Abscess
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Benign Intracranial Hpertension
“Pseudotumor cerebri”
�� Young, obese womenYoung, obese women
�� Pathogenesis not clearPathogenesis not clear
�� Precipitating factors:Precipitating factors:
–– HypoparathyroidismHypoparathyroidism
–– Vitamin A excess (Vitamin A excess (TxTx of acne)of acne)
–– Pernicious anemiaPernicious anemia
–– Drugs: oral contraceptives, tetracycline, Drugs: oral contraceptives, tetracycline, sulphamethoxazolesulphamethoxazole, , indomethacinindomethacin, a.o., a.o.
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Benign Intracranial Hypertension
Presenting Features
�� HeadacheHeadache
�� Visual disturbanceVisual disturbance
–– Blurred visionBlurred vision
–– DiplopiaDiplopia
�� PapilledemaPapilledema
�� Optic atrophyOptic atrophy
�� 66thth nerve palsynerve palsy
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�� CT CT –– scan: WNLscan: WNL
�� Lumbar puncture & measurement of Lumbar puncture & measurement of
CSF pressure: ElevatedCSF pressure: Elevated
�� CSF biochemical & cytological: WNLCSF biochemical & cytological: WNL
�� MRI & MRA: WNLMRI & MRA: WNL
�� Continuous intracranial pressure Continuous intracranial pressure
measurement (in doubtful cases) measurement (in doubtful cases)
Benign Intracranial Hypertension
Investigations
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Benign Intracranial Hypertension
Treatment
�� Weight reductionWeight reduction
�� Discontinuation of potentially causative Discontinuation of potentially causative
drugs ( e.g. contraceptives, vitamin A)drugs ( e.g. contraceptives, vitamin A)
�� Diuretics (e.g. Diuretics (e.g. LasixLasixRR))
�� AcetazolamideAcetazolamide ((DiamoxDiamoxRR): Initially 500 ): Initially 500
mg, later 250 Q6hmg, later 250 Q6h
�� Intermittent release of CSFIntermittent release of CSF
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Benign Intracranial Hypertension
Indication of Surgery
�� Persistent papilledema despite Persistent papilledema despite TxTx
�� Failing visionFailing vision
�� Intractable headache despite Intractable headache despite TxTx
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Benign Intracranial Hypertension
Surgical Treatment
�� LumboLumbo--peritoneal shuntperitoneal shunt
�� Optic nerve sheath decompressionOptic nerve sheath decompression
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Complications of Untreated
Raised ICP
�� DeathDeath
�� Neurological disabilityNeurological disability
–– BlindnessBlindness
–– Mental impairmentMental impairment
–– Motor disabilityMotor disability
�� DisfigurementDisfigurement
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Neurological Disability
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Measurement of Intracranial
Pressure
�� EpiduralEpidural
�� SubduralSubdural
�� IntraparenchymalIntraparenchymal
�� IntraventricularIntraventricular
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Intraventricular Pressure Measurement
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A-waves or Plateau waves
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Measurement of Intracranial
Pressure Indications
�� Severe head traumaSevere head trauma
�� IntracerebralIntracerebral hemorrhagehemorrhage
�� Extensive cerebral edema Extensive cerebral edema
–– e.g. after infarct, hypoxia, intoxication, etc.e.g. after infarct, hypoxia, intoxication, etc.
�� Following major intracranial operationsFollowing major intracranial operations
�� In the assessment of dementia and In the assessment of dementia and
benign intracranial hypertensionbenign intracranial hypertension
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References
�� Essential NeurosurgeryEssential Neurosurgery
by: Andrew Kayeby: Andrew Kaye
�� Neurology and Neurosurgery IllustratedNeurology and Neurosurgery Illustrated
by: Lindsay by: Lindsay -- Bone Bone -- CallanderCallander
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