INTRA CRANIAL

PRESSURE
ZARKA WAHID BUX
SIUT SCHOOL OF NURSING

06/26/2020

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WHAT IS ICP
…the pressure within
the cranium that is
exerted by the BRAIN
BLOOD
combined total volume TISSUE

of the 3 components
within the skull
CSF

MONROE-KELLIE DOCTRINE

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 CEREBROSPINAL FLUID
Secreted at the rate of 500 mls per day.
Secreted by the choroid plexus in the lateral ventricles .
Flows through the ventricular system .
Absorbed into the venous system via the arachnoid
granulations .
Any obstruction to the flow will lead to HYDROCEPHALUS and
increased pressure.

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CEREBRAL BLOOD FLOW

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CEREBRAL BLOOD FLOW (CBF)
Cerebral blood flow (CBF) is the blood supply to the brain in a
given period of time. In an adult, CBF is typically 750 milliliters
per minute or 15% of the cardiac output. This equates to an
average perfusion of 50 to 54 milliliters of blood per 100 grams
of brain tissue per minute

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INTRACRANIAL CONTENT
Brain 80 – 85 %
CSF 8 – 12%
Cerebral blood volume 5 – 8 %
Total Intra cranial volume 1500 ± 100ml

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INTRACRANIAL PRESSURE
Normally 0-140 mm CSF (0-10 mm Hg)
There are normal regular waves due to pulse and respiration
With increased pressure “pressure waves” appear
With continued rise of ICP the PP falls
When PP falls CBF is reduced
Electrical cortical activity fails if CBF is 20ml/100gm/min
When intracranial pressure reaches mean arterial pressure
circulation to the brain stops

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INCREASED ICP
Increased ICP is defined as a sustained elevation in pressure
above 20mm of Hg
ICP <15 mm of Hg – Intracranial hypertension • Acute • Chronic

levels ICP in mmHg

normal 5 - 15
mild 16 - 20
moderate 21 -30
severe 31 -40
Very severe 41 & above

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PATHOPHYSIOLOGY OF
INCREASED ICP
Increased pressure within the cranial cavity (or skull) is caused
by an increase in the volume of either the brain tissue, blood, or
cerebrospinal fluid, or by the presence of another space-
occupying lesion. This increased pressure will compress the
brain tissue, causing damage to the neurons and leading to
neuro changes and eventually herniation and brain death.

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ETIOLOGY OF ICP
A tumor in brain
Swelling in the brain
Encephalitis
Bleeding into the brain hemorrhagic stroke or aneurysm
headache

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FACTORS CAUSING INCREASED
ICP
Cerebral Oedema
Vasogenic
Hypoxemia
Hyponatremia/ Water Intoxication
Post-Cardiac Arrest
Inflammatory—Meningitis/Encephalitis
Interstitial oedema
Intra Cranial Space Occupying Lesions
Enlarged ventricular system
Increase in Cerebral blood flow
Impaired cerebral venous drainage

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SIGN AND SYMPTOM OF ICP
:
Decreased level of consciousness
Confusion, agitation, restlessness, aggressiveness
 Personality changes
 Headache (vision changes) lack of peripheral vision
 Nausea and vomiting
 Change in speech pattern .eg slurred speech clear speech
that doesn’t make sense
 Seizures
 Abnormal posturing

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ASSESSMENT
Two types of neurological exam
 Rapid neuro exam
 Glasgow coma scale ,LOC, orientation, movement of arms and
legs, pupil reaction to light.
 Complete neuro exam.
 LOC mental status, memory and attention, PERRLA, Cranial
nerves, motor function .deep tendon reflexes
 Comparing one side to the other (left –right)
 Subtle changes can be found with comparison

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POSTURING WITH INCREASED
ICP

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INTRACRANIAL PRESSURE (ICP)
MONITORING
● An ICP monitor is a device inserted into the cranial cavity that
records pressure and is connected to a monitor that shows a
picture of the pressure waveforms.
Monitoring ICP facilitates continual assessment and is more
precise than vague clinical manifestations.
The insertion procedure is always performed by a
neurosurgeon in the operating room, emergency department,
or critical care unit. This procedure is rarely used unless the
client is comatose, so there is minimal need for pain medication
and pre procedural teaching

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● THREE BASIC TYPES OF ICP
MONITORING SYSTEM
◯ Intraventricular catheter (also called a ventriculostomy)
■ A fluid-filled catheter is inserted into the anterior horn of the
lateral ventricles (most often on the right side) through a burr
hole. The catheter is connected to a sterile drainage system
with a three-way stopcock that allows simultaneous monitoring
of pressures by a transducer connected to a bedside monitor
and drainage of CSF.

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SUBARACHNOID SCREW OR
BOLT
Subarachnoid screw or bolt
A special hollow, threaded screw or bolt is placed into the
subarachnoid space through a
twist-drill burr hole in the front of the skull, behind the
hairline. The bolt is connected by
fluid-filled tubing to a transducer leveled at the approximate
location of the lateral ventricles.

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EPIDURAL OR SUBDURAL SENSOR

Epidural or subdural sensor

■ A fiber-optic sensor is inserted into the epidural space
through a burr hole. The fiber-optic
device measures changes in the amount of light reflected from a
pressure-sensitive diaphragm
in the catheter tip. The cable is connected to a monitor that
displays the numerical value of ICP. This method of monitoring
is noninvasive because the device does not penetrate the Dura.

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INDICATION

ICP monitoring is useful for early identification and treatment of

increased intracranial pressure.
Clients who are comatose and/or have GCS scores of 8 are candidates
for ICP monitoring. patient Presentation
■ Symptoms of increased ICP include severe headache, deteriorating
level of consciousness,
restlessness, irritability, dilated or pinpoint pupils, slowness to react,
alteration in breathing
pattern (Cheyne Stokes respirations, central neurologic
hyperventilation, apnea), deterioration
in motor function, and abnormal posturing (decerebrate, decorticate,
flaccidity).

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INTERPRETATION OF FINDINGS

● Interpretation of Findings
◯ Normal ICP is 10 to 15 mm Hg. Persistent elevation of ICP
extinguishes cerebral circulation, which will result in brain
death if not treated urgently.

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PRE AND INTRA PROCEDURE
NURSING MANAGEMENT
Pre procedure
◯ The head is shaved around the insertion location. The site is
then cleansed with an antibacterial solution
◯ Local anesthetic can be used to numb the area if the client’s
GCS indicates some level of consciousness (GCS 8 to 11).
◯ Insertion and care of any ICP monitoring device requires
surgical aseptic technique to reduce the
risk for CNS infection.

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POST PROCEDURE

Nursing Actions
■ Maintain system integrity at all times. There is a risk of serious, life-
threatening infection.
■ Inspect the insertion site at least every 24 hr for redness, swelling, and
drainage. Change the sterile dressing covering the access site per facility
protocol.
■ ICP monitoring equipment must be balanced and recalibrated per facility
protocols.
■ After the insertion procedure, observe ICP waveforms, noting the pattern
of waveforms and monitoring for increased ICP (a sustained elevation of
pressure above 15 mm Hg).
■ Assess the patient clinical status and monitor routine and neurologic
vital signs every hour as needed.

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COMPLICATION
Infection and bleeding
■ The insertion and maintenance of an ICP monitoring system
can cause infection and bleeding.
■ Nursing Actions
Follow strict surgical aseptic technique.
Perform sterile dressing changes per facility protocol.
Keep drainage systems closed.
Limit monitoring to 3 to 5 days.
Irrigate the system only as needed to maintain patency

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