NEUROSURGICAL APPROACH

ON MEASURING AND TREATING

INCREASE INTRACRANIAL PRESSURE
Hanif G Tobing, MD
Affan Priyambodo, MD
Abdi Reza, MD

Department of Neurosurgery
Faculty of Medicine, Universitas Indonesia
Cipto Mangunkusumo General Hospital

Neuro Emergency 2016 Saturday, Oct 1st 2016

Ancient Surgery

 Headache!!!
 Trephination 
1st Surgery

Source: google.co.id
Keyword: Trephination, Ancient
surgery, First surgery
Increased Intracranial Pressure
Monroe – Kellie Doctrine
Skull
 Closed Skull Concept
Monroe-Kellie Doctrine
 Alexandre Monroe, 1783
 Harvey Cushing, 1926
 Brain encased in RIGID structure ‘with an intact skull, the volume of the
 Brain is incompressible brain, blood, and CSF is constant.
An increase in one component will
 Cranial blood volume must be CONSTANT cause a decrease in one or both of
 Constant venous drainage needed for the other components’
arterial supply
 George Kellie
 Vesallius , CSF concept
 Francois Magendie, 1842
 CSF puncture
 George Burrows, 1846
 Blood – CFS relation concept
Skull, Brain, Blood, CSF Brain consume 20% Oxygen
Autoregulation  constant blood supply
CBF ~50 ml per 100 g brain tissue per min
MAP 50 – 150 mmHg
CPP 60 – 160 mmHg
ICP
Acute vs Chronic

Compensatory reserve:
•Young 60 – 80
•Elderly 100- 140
 • Skull embryology
Embryology - Anatomy • Cranial Suture Concept
• Fontanelle Concept

Large Fontanelle Closure 18 mo

Cranium Thickening 6 years
  Fontanelle – Cranial Suture
 Brain Growth
Closed Skull Concept
Skull is ROCK!!!
Increased ICP Effect
Anatomical point of view
Herniation
Functional Clinical Anatomy

Youman’s Neurological Surgery 4th Ed;

Chapter 335: Surgical Management of
Traumatic Brain Injury
Causes

Source: www.noninvasiveicp.com
Measuring Increased ICP
Indication
Type
 Indication

 AANS guidelines for Traumatic Brain Injury

Type

Invasive Non - Invasive

 External Ventricular Drainage  Trans Cranial Doppler

 Epidural Catheter  Tympanic Membrane
 Cateheter-tip Micro Transducer Displacement
 Lumbal Drainage  Optic Nerve Sheath Diameter
 MRI – CT
 Funduscopy – Papilledema
 EEG
Youman’s Neurological Surgery 4th Ed;
Chapter 335: Surgical Management of
Traumatic Brain Injury
Is it Useful? RCT ICP vs Clinical - CT
Treating Increased ICP
Skull
Brain
CSF
Blood
Mass
Staircase Algorithm severe TBI ; Time is Brain

Youman’s Neurological Surgery 4th Ed;

Chapter 335: Surgical Management of
Traumatic Brain Injury
 Mass; Intrinsic – Extrinsic Tumor, Hematoma
Removal tumor or blood – with or w/o bone extraction

Female 50 yo
Decrease of What is the cause
conscioussness for decrease of
1 week conscioussness?

What is the
Headache underlying problem ?
Blurred vision
Right side body What is your next
weakness plan?
Head MRI with contrast
Pre operative head CT scan Post operative head CT scan
Skull; Craniosynostosis – Apert Synd, Depressed Fracture
Suturectomy, facial effacement, bone reconstuction

Dura
CSF; Hidrocephalus (Production, Circulation, Absorption)
Fluid Diversion: External Ventricular Drainage, Shunt, Lumbal Drainage/Shunt
Endoscopic Third Ventriculostomy

ETV

VP Shunt VA Shunt
Brain; Edema (cytotoxic – vasogenic), DAI, Contusio
Decompressive Surgery

Acute MCA Infarction Contusio

Severe Edema
ANCORA
IMPARO
 Blood
Vasospasm, Cerebral Venous Disease

SAH – Aneurysm Rupture

Cerebral Venous Ocllusion

Surgical Clipping or
Neurointerventional
Headache???
Role of Primary Physician
 To perform closed observation of patient with increase ICP
 To perform non surgical treatment for increased ICP
 To perform early consultation to Neurology – Neurosurgery
team
Conclusion
 Monroe – Kellie Doctrine
 ‘with an intact skull, the volume of the brain, blood, and CSF is constant. An increase in
one component will cause a decrease in one or both of the other components’
 Time is Brain
 Nothing can replace Closed Neurological Observation and
Serial CT
 Teamwork  Primary Physician – Neurology & Neurosurgery
Team
Sign of Increased ICP