INTRACRANIAL PRESSURE

Dr. Akhmad Imron, SpBS

Dept. of Neurosurgery
 INTRODUCTION

• Our skull creates a hard casing in

which our cranial contents rest
and are protected from injury.
• The cranial contents consist of
three components. Brain tissue or
cells make up 80 –85% of the
cranial contents. Our
cerebrospinal fluid averaged 8 –
12% and cerebral blood volume is
3 – 5%.
• When there is an increase in one
of the three components, it
normally results in a decrease on
one or both of the other.
• This permits for stability of
contents within the skull vault.
To maintain this stability the body has three
compensatory mechanisms that are utilized.
The first is the autoregulation of the brain.
Autoregulation facilitates continual cerebral
perfusion of brain tissue regardless of changes in
systemic arterial blood pressure. When a person
has a rise in blood pressure, the arterioles of the
brain will constrict to maintain a constant amount of
blood circulating within the tissue. If the person has
a drop in blood pressure, the arterioles will dilate to
permit more blood flow into the cerebral circulation.
The second compensatory mechanism of the brain
is cerebrospinal fluid regulation. This is the
slowest of the compensatory mechanisms. It will
regulate the production and re-absorption of the
CSF with any changes in intra-cerebral volume.
If there is an increase in cerebral contents, this
mechanism will decrease the production of CSF
and call for an increase in re-absorption.
Ultimately it will cause a decrease in intracranial
pressure.
The last compensatory mechanism of the brain to
maintain stability is via metabolic regulation.
When there is a decrease in oxygen being fed to
the brain tissue, there will be a subsequent
increase in carbon dioxide. These changes
cause a vasodilatation within the brain permitting
increased blood flow to the brain. Hyperthermia
causes an increased metabolic rate in the brain.
This increased metabolic rate increases oxygen
and glucose consumption, the two major needs
for proper brain functioning
 INTRACRANIAL PRESSURE

• Intracranial pressure (ICP) is defined as the

measure of cerebrospinal fluid pressure within
the cranium.
• Normal ICP ranges from 0 – 15 mm Hg.
• A resting ICP value greater than 20 mm Hg is
defined as intracranial hypertension and may be
acute or chronic in nature.
• Increased ICP can result in irreversible damage
to the cranial contents by impairing blood flow
and eventually cause death if left untreated.
INCREASED INTRACRANIAL PRESSURE

• Elevation in ICP can be graded as follows:

• Normal ICP 0 – 15mm Hg

• Mile elevation 16 – 20 mm Hg
• Moderate elevation 21 – 30 mm Hg
• Sever elevation 31 – 40 mm Hg
• Very severe elevation 41 mm Hg and above
 ETIOLOGY OF INCREASED ICP

• Cerebral edema can be one of the causes for

intracranial pressure to increase. Other causes
include:

• Blood clots or expanding lesions

• Abscess or infection
• Enlarged ventricles due to increased CSF volume
• Pneumocephalus
• Increased cerebral blood flow
• Increased thoracic pressure
• Impaired cerebral venous drainage
 ICP MONITIRING
Mean Arterial Pressure (MAP) – ICP = CPP

• Mean Arterial Pressure is calculated as

below:

Systolic BP + (2 x Diastolic BP) ÷ 3 = MAP

 SIGN AND SYMPTOM
• can be very subtle ,It may include:

• Restlessness
• Agitation
• Mild confusion
• Personality changes
• Decreasing Glascow Coma Score
• Headache (usually early morning with noted
vomiting)
• Slowed or slurred speech
 SIGN AND SYMPTOM
• Memory impairment
• Decreased hand grasp or paresis
• Decreased response to touch or pinprick
• Pupils will be delayed or sluggish to react to light. Shape
will become ovoid or they will become unequal.
• Vision may become blurred with decreased visual acuity
• Seizure activity may or may not be present
• Vital signs are unchanged at this time
 HERNIATION SYNDROMES

• Increasing intracranial pressure if left untreated

will lead to cerebral herniation of brain tissue.
• Herniation is defined as the protrusion of a portion
of the brain through an abnormal opening.
• No matter what is causing the increasing
pressure, it will cause brain tissue to shift from the
area of high pressure to an area of low pressure.
• There exists two categories of herniation, the
supratentorial and the infratentorial
 Supratentorial Herniation

There are four types of

supratentorial herniations:
• Cingulate herniation
• Central or
Transtentorial
herniation
• Uncal or Lateral
Transtentorial
herniation
• Transclavarial
herniation
 Infratentorial Herniation
There are two forms of
infratentorial
herniation:
• Tonsillar or
Downward
Cerebellar
herniation
• Upward
transtentorial
herniation
 INTERVENTIONS FOR THE PATIENT WITH
INCREASED ICP

• Nursing Management includes:

• Maintain the patients head midline to facilitate blood flow.
• Maintain the head of the bed at 30 – 45 degrees to facilitate
venous drainage.
• Avoid activities that can increase ICP such as suctioning or
gaging.
• Treat hyperthermia as it increases the metabolic needs of the
brain.
• Decrease environmental stimuli which can increase ICP.
 •. Maintain fluid balance via accurate I & O.
Overhydration will lead to cerebral edema.
• 7. Monitor electrolytes as these patients are
prone to hypernatremia, hypoglycemia, and
hypokalemia with diuretic useage.
• 8. Monitor hyperventilation to maintain CO2
levels at 25 – 35mm Hg to prevent vasodilation.
• 9. Use of Lidocaine prior to suctioning to
decrease gag reflex.
•
Medical Management includes:
• Anticonvulsant therapy for seizures.
• Use of diuretics such as Mannitol, Urea, and Glycerol.
• Barbiturate Coma Therapy to decrease the metabolic demands
of the brain.
• 50% Dextrose solution if hypoglycemia is present and persistent.
• Corticosteroid therapy witch remains controversial.
• Intracranial pressure monitoring with drainage abilities.

Surgical decompression
– - considered life saving measure
– - opening of the skull can lead to severe herniation
THANK YOU