Cerebral edema
Increased Intracranial
Pressure (IICP)
Intracranial Pressure (ICP)- pressure in the skull
that results from the volume of 3 essential
components:
 CSF, 75ml
 BLOOD VOLUME, 75ml
 CNS TISSUE, 1400g
- The normal ICP is between 5-15 mmHg.
- 3 components maintain a state of
equilibrium.
- The intact cranium cannot be expanded
Monroe-Kellie hypothesis- because of a limited
space for expansion within the skull, an increase
in any one of the components causes a change
in the volume of the others.
- Any increase in one of the elements
must be balanced or compensated by a
proportional constriction either or both
of the other components.
Increased Intracranial Pressure (IICP)
- A syndrome characterized by increase in the
amount of CNS tissue or CSF fluid leading to
an ICP greater than 15mmHg.
- Once ICP reaches around 25mmHg marked
elevation in ICP will be noted.
- Normally, a change in CSF & blood volume
occurs during exhalation, valsalva
maneuver, sneezing, coughing & straining
at stool.
- CSF- overproduction, accumulation,
impediment in CSF flow, surgery
- CNS tissue- head injury, cerebral edema,
brain tumor, CNS infections, space
occupying lesions
- Blood- intracranial bleeding, hematoma
(subdural), increased carbon dioxide partial
pressure.
PATHOPHYSIOLOGY
Brain (bony skull)
↓  Decortication- indicates
No room for expansion
↓ abnormal flexion of the UE &
Increase in the bulk of the brain
↓  Decerebration- indicates
Compression/displacement of brain structures
& blood supply
↓ lower extremities
Cerebral ischemia, hypoxia-(acidosis,necrosis)
↓
Inflammation
↓
↓
Increase intracranial pressure
Clinical Manifestations
**When ICP increases to the point where the
brain’s ability to adjust has reached its limits,
neural function is impaired. (changes in LOC)
 lethargy the earliest sign
 Sudden change in condition, such as
restlessness, confusion (without
apparent cause)
 Pt. becomes stuporous & may react
only to loud auditory or painful stimuli.
 When coma is profound, pupils are
dilated & fixed, respirations are
impaired----death.
 Cushing’s triad (bradycardia, bradypnea
& HPN); widening pulse pressure---is an
ominous sign
Assessments
 Headache (constant with increasing
intensity, aggravated by movements)
 Vomiting results from pressure at the
medulla oblongata. (projectile)
 Diplopia
 Body temperature may be elevated or
subnormal
 Pupillary changes; anisocuria (CNIII
compression),
 Papilledema; results from the
compression of the optic nerve, also
known as choked disk.
 Lateralizing sign; this is a contralateral
loss of motor function due to
decussation of motor fibers at the level
of medulla oblongata.
 Brainstem function impairment;
 Doll’s eye phenomena- abnormal
when present & may occur as the
client begins to experience a
decrease in LOC. Occurs when the
client’s head is moved from side to
side & the eye remain in a fixed
midline position
involvement of above the midbrain;
extension of LE
involvement of the brainstem;
Extreme extension of the upper &
 Medical Management Complications
 Tentorial, lateral transtentorial &
**Increased ICP is a true emergency & must be
central herniation
treated promptly..
 Seizures
 Invasive monitoring of ICP
 Cognitive deficits
 Decreasing cerebral edema
 Lowering the volume of CSF  Motor deficits
 Decreasing cerebral blood volume while  Sensory deficits
maintaining cerebral perfusion  Coma
 Pharmacologic therapy  Death
 Patient requires care in the critical care
unit.

Pharmacotherapy
 Diuretics; use to dehydrate the brain
tissue & reduce cerebral edema
(mannitol, lasix)
 Anticonvulsants (valium, dilantin,
phenobarbital, tegretol)
 Antipyretics/muscle relaxant
 BP medication
 Corticosteroids; to reduce cerebral
edema by its anti-inflammatory effect.
Decadron(dexamethasone)
 Antacids/H2 receptors (prevent stress
ulcers)
 Anticoagulants
 Stool softener
 Intravenous fluids (avoid hypotonic
solutions)
 Electrolyte replacement

Note: Opiates & sedatives are contraindicated

to the client with IICP.

Treatment & Collaborative Management

 Position: Semi-fowlers; pt.’s head is
kept in neutral(midline) position,
maintained with the use of cervical
collar; HOB 15 to 30 degree
 Adequate oxygenation/maintain
respiratory function
 Protect patient from injury (seizure
precaution, maintain a quiet/non-
stimulating environment)
 Avoid factors that increases ICP (N&V,
sneezing/coughing, straining, too much
suctioning, restraints, rectal
examination, enema, bending/stooping,
oversuctioning)
 Control hypertension/fever
 Monitor intake & output
 Limit fluid intake to 1200ml/day

Surgical Intervention
 Ventriculoperitoneal shunt- shunts CSF
from the ventricles into the peritoneum
 Craniotomy for space occupying lesions
and cerebral hematoma