INTRACRANIAL

PRESSURE(ICP)
MOHD ROSLEE BIN ABD GHANI
LEARNING OBJECTIVES

• Define ICP
• Explain the causes of increasing ICP
• State the signs and symptoms of ICP
• State the indication and contraindication of ICP monitoring
• State the methods of ICP monitoring
• Describe the management of ICP
DEFINITION

• Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF)
inside the skull and on the brain tissue.
• ICP is measured in millimeters of mercury (mmHg) and, at rest, is normally 7–15 mmHg for a
supine adult
• The body has various mechanisms by which it keeps the ICP stable, with CSF pressures
varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF.
• Changes in ICP are attributed to volume changes in one or more of the constituents contained
in the cranium.
INTRACRANIAL HYPERTENSION (IH)

• Intracranial hypertension (IH), also called increased ICP (IICP) or

raised intracranial pressure (RICP), is elevation of the pressure in the
cranium.

• ICP is normally 7–15 mm Hg; at 20–25 mm Hg, the upper limit of normal,
treatment to reduce ICP may be needed.
SIGNS AND SYMPTOMS

• Headache • altered level of consciousness,

• classically morning headache
• back pain and
• Worsen during the night due to the
lying position • papilledema.
• Worse on coughing, sneezing or
• behavioral changes
bending

• vomiting without nausea, • pupillary dilatation,

• ocular palsies, • abducens palsies

SIGNS AND SYMPTOMS…

• Cushing's triad.
• Cushing's triad involves an increased systolic blood pressure, a widened pulse pressure,
bradycardia, and an abnormal respiratory pattern.

• In children, a low heart rate is especially suggestive of high ICP.

• Irregular respirations
• Biot’s respiration in which breathing is rapid for a period and then absent for a
period, occurs because of injury to the cerebral hemispheres or diencephalon.
• Hyperventilation can occur when the brain stem is damaged
CAUSES

• Mass effect such as brain tumor,

• infarction with edema,
• Brain contusions,
• subdural or epidural hematoma, or
• Brain abscesses
• Generalized brain swelling can occur in ischemic-anoxia states,
• acute liver failure
• hypertensive encephalopathy
CAUSES….

• hypercapnia
• Increase in venous pressure can be due to venous sinus thrombosis,
• heart failure, or obstruction of superior mediastinal or jugular veins
• Obstruction to CSF flow and/or absorption can occur in hydrocephalus
• extensive meningeal disease (e.g., infection, carcinoma, granuloma, or hemorrhage),
• meningitis,
• subarachnoid hemorrhage, or
• choroid plexus tumor.
• Idiopathic or unknown cause
ICP MONITORING

• Indications for ICP Monitoring

• severe head trauma,
• CSF circulatory disorders
• traumatic brain injury (TBI),
• hydrocephalus
• Intracranial bleeding
• idiopathic intracranial hypertension, or Reye’s syndrome
ICP MONITORING…

• Contra-indications
• coagulopathies or anti-coagulation medication,
• scalp infections, or
• brain abscess.
TYPES OF ICP MONITORING

• There two basic ICP monitor types are via ICP data only (commonly known as ‘bolts’)
or ICP data plus CSF drainage.
• The three main types of ICP monitor are;
1. External Ventricular Drain (EVD),
2. Subarachnoid Bolt, and
3. Epidural bolt.

• These probes can often also be used to measure other physiological parameters,
including temperature, lactate, and pH.
TYPES OF ICP MONITORING…

Subarachnoid Bolt
• The subarachnoid bolt is a small and unobtrusive device, allowing for a good waveform
resolution of ICP.
• It is relatively easy to install and is less invasive than EVD.
• However, it does come with several limitations, including lack of therapeutic uses,
unable to be recalibrated following installation, and the transducer tip becoming
obstructed if it comes into contact with brain parenchyma, as well as a higher infection
risk and lack of discrimination of infratentorial pressures.
TYPES OF ICP MONITORING…

Epidural bolt
• An epidural bolt also has the limitation of a lack of therapeutic use.
• It also has more pronounced signal attenuation so often will
underestimate the ICP.
• However, it does have a decreased infection risk, which confers
advantage over the subarachnoid bolt.
TYPES OF ICP MONITORING…

External Ventricular Drain

• The External Ventricular Drain (EVD), also termed fluid-filled transduced ventriculostomy, is the
gold standard intervention for raised ICP
• Its main benefits include additional uses for therapeutic aspiration of CSF, rarely will occlude, and
inexpensive, albeit difficult to install.
• Its limitations include infection (ventriculitis) and potential for damage to the underlying brain
parenchyma.
• They are most commonly inserted into Kocher’s point, however alternative points for EVD insertion
include Keen’s point, Frazier’s point, and Dandy’s point
TREATMENT

Treatment / Management
• Assessment and management of airway, specifically breathing
and circulation should always be the priority.
• Management principles should be targeted toward:
• Maintenance of cerebral perfusion pressure
• Treatment of the underlying cause.
• Lowering of ICP.
TREATMENT

Measures to lower ICP include:

• Elevate of the head of the bed to greater than 30 degrees.
• Keep the neck midline to facilitate venous drainage from the head.
• Hypercarbia lowers serum pH and can increase cerebral blood flow contributing to rising ICP,
hence hyperventilation to lower pCO2 to around 30 mm Hg can be transiently used.
• Osmotic agents can be used to create an osmotic gradient across blood thereby drawing fluid
intravascularly and decreasing cerebral edema. Mannitol was the primary agent used at doses
of 0.25 to 1 g/kg body weight and is thought to exert its greatest benefit by decreasing blood
viscosity and to a lesser extent by decreasing blood volume.
TREATMENT….

Measures to lower ICP include….

• Drugs of the carbonic anhydrase inhibitor class, such as acetazolamide, can be used to
decrease the production of CSF and is used to treat idiopathic intracranial hypertension.
• Lumbar punctures, besides being diagnostic, can be used to drain CSF thus reducing the ICP.
• EVD can also be used to not only monitor ICP but also to drain CSF.
• Ventriculoperitoneal or lumbar-peritoneal shunts can divert CSF to another part of the body
from where it can be reabsorbed.
• Neurosurgical shunts such as A decompressive craniectomy is a last resort when all other ICP
lowering measures have failed.
COMPLICATION

• Meningitis
• Ventriculitis
• Wound infection
• Intracranial haemorrhage
• Ventricular collapse
THANK YOU