TEKANAN INTRAKRANIAL

Hendra Supriawan
1806271964

Neuro-Onkologi Topic Discussion

Februari 2020
 Introduction
• Elevated intracranial pressure (ICP) and hydrocephalus are tumor-
associated phenomena that are frequently observed in brain tumor
patients.
• Left untreated, these factors can lead to significant functional
disability or loss of life.
• Effective management of ICP and hydrocephalus can improve quality
of life and prolong the survival of brain tumor patients

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 Introduction

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ETIOLOGY
1. Generalized swelling of the brain or cerebral edema from a variety
of causes such as trauma, ischemia, hyperammonemia, uremic
encephalopathy, and hyponatremia
2. Mass effect
3. Increase in cerebrospinal fluid
4. Decreased re-absorption of CSF
LCS
• CSF volume total 150ml, of
which 75ml is in cranium and
75ml is in spinal canal. CSF
volume in cranium could
increase if there is
hydrocephalus
• Cerebral blood volume
corresponds to cerebral
blood flow, which is
controlled by several factors
(see next section)
 ICP in Brain Tumor Patient
• The cranial vault is an enclosed and
environmentally controlled space that
is designed to protect the components
of the central nervous system.
• It contains three major components:
brain tissue, blood, and cerebrospinal
fluid (CSF) [1].
• Together, these three components
completely fill the intracranial space.
An increase in any one of these three
components will lead to an increase in
ICP
Metabolic Autoregulation

• Linear relationship between O2

consumption and blood flow
• cerebral blood flow is determined
in part by cerebrovascular
resistance and by cerebral
perfusion pressure or CPP, which is
the difference between mean
arterial pressure (MAP) and ICP
(i.e., CPP = MAP-ICP)
paCO2 vs CBF

• ↑ CBF by 4% for every ↑

paCO2 of 1mmHg
between paCO2 of 20 –
80mmHg
• Lower inflection point –
limited by hypoxaemia →
vasodilatation
• Upper inflection point –
maximal vasodilatation
paO2 vs CBF

• ↑ CBF by 4% for every ↑

paCO2 of 1mmHg
between paCO2 of 20 –
80mmHg
• Lower inflection point –
limited by hypoxaemia →
vasodilatation
• Upper inflection point –
maximal vasodilatation
Pressure Autoregulation

• CBF maintained constant

between MAP of 50 – 150mmHg
• Lower inflection point – maximal
vasodilation
• Upper inflection point – high
pressure overcomes
vasoconstriction
• Even in cases where the ICP is
sustained at levels greater than
40 cm of water, patients can
experience a good functional
outcome as long as the CPP is
maintained at an acceptable
level, i.e., CPP greater than 60
mm of water [25].
Physiological Effects of Elevated IC

1. Decrease cerebral blood flow

2. Elevations in ICP can generate
pressure gradients that cause
shifts in the anatomic position
of the nervous system
3. Ischemic injury
4. Death
Signs and Symptoms of Elevated ICP
• These headaches can be localized or generalized in nature, and are
often worse in the morning
• Recurrent nausea or vomiting.
• visual deficits
• In cases of extreme elevations in ICP, hypertension and bradycardia
(the Cushing reflex) may occur
• altered mental status or episodes of loss of consciousness.
 Increased Tumor Volume and Edema as Causes of
Elevated ICP.
• As the growing tumor mass crowds
brain tissues and fluids that are normally
present within the intracranial space,
elevations in ICP result
• elevations in ICP caused by the added
volume of the tumor mass can also lead
to decreased cerebral blood flow and
ischemic injury, independent of direct
tissue compression
• Tumors that secrete angiogenic factors
such as VEGF  edema vasogenik
• Obstructive Hydrocephalus
Obstructive Hydrocephalus and Elevated ICP
Communicating Hydrocephalus and ICP

• Some investigators have postulated that proteins secreted by the

tumor decrease CSF absorption
• Choroid plexus tumors (i.e., choroid plexus papilloma and choroid
plexus carcinoma)
• infiltration of the meninges by tumor cells, a phenomenon known as
leptomeningeal carcinomatosis
• lumbar puncture can be
performed safely. The ICP
is usually elevated, less
glucose and more protein
than the CSF of healthy
patients.
Normal Pressure Hydrocephalus in Brain Tumor
Patients
• Patients who have central nervous system tumors or who have
received radiation and/or chemotherapy for such tumors can develop
a form of communicating hydrocephalus that is not associated with
severe elevations in ICP.
• The mechanisms underlying the development of NPH after brain
tumor treatment are poorly understood.
• Cranial imaging shows evidence of ventricular enlargement in most
cases
Medical Management of Elevated ICP in Brain
Tumor Patients
• Dexametason (Glukokortikoid)
• Anti- VEGF (Bevacizumab)
Bevacizumab has been shown to decrease cerebral edema by
“normalizing” leaky vessels, thereby decreasing mass effect and
reducing ICP
bevacizumab has become a useful alternative to dexamethasone for
controlling ICP

•
Tumor Resection and Radiation for Treatment of
Elevated ICP in Brain Tumor Patients
• The long-term goal of ICP management in many brain tumor patients
can be achieved by tumor removal
• such as germinomas or papillary tumors of the pineal region,
lymfoma radiation can cause rapid regression of these tumors,
thereby relieving the obstruction of CSF flow.