RAISED

INTRACRANIAL
PRESSURE BY
D R . TA L L AT P E R V A I Z A L I
•First Normal (ICP)
•Then Abnormal ( ICP)
ICP
• Definition
• Pressure exerted by the volume of the contents in the rigid box of
skull.
• ICP is Sum of individual pressures of Brain

Brain, Blood and CSF

Blood

CSF
ICP

•Increase With age (Range 5-15mmHg)

• Neonate 2mmHg
• Child 7-9mmHg

• High >20 mmHg

• Very High >40mmHg
ICP

• Normal Functioning of brain requires

• constant cerebral blood flow of 60-70ml/min/100gm Brain

• Electrical activity in the cortex fail if blood flow is 20 or
<20ml/min/100gm Brain
CPP (CER EB R AL P ER FUSI O N P R ESSUR E)

• Pressure gradient:
• high pressure outside the Skull that is systematic blood pressure
(MAP)
Low pressure inside the skull Intracranial pressure
(ICP)

CPP= MAP-ICP
MAP

2 1
1. 3
𝐷𝑃 +
3
𝑆𝑃
2 𝐷𝑃 +𝑆𝑃
2. 3
1
3. 𝐷𝑃 +
3
𝑃𝑃
AUTO REGULATION
• C.B.F is well (60-70ml/min/100gm Brain) Maintained despite fluctuation in the CPP with in the
limit of 50-150mmHG.
• Outside this limit auto
regulation failed

50 150

CPP
AUTO REGULATION

• CPP <50mmHg Ischemia

• CPP >150mmHg Cerebral Edema
CHEMO REGULATION
Decreased
ICP

Cerebral Vasodilation
𝑃𝐶𝑂2
𝑃𝑂2
Extracellular PH

Metabolic by- produts 𝑃𝐶𝑂2

Extracellular PH

Cerebral Vasodilation Metabolic by- produts

Raised ICP
 Raised ICP (Interrelationship)
Venous out Cerebral edema
flow OBS
ICP CSF outflow
Cerebral
Vasodilation
Expending mass

CPP

𝑃𝐶𝑂2
PH
Brain Damage
Systemic CBF
𝑃𝑂2 B.P
(<50 mmHg)
Brain Hypoxia
 CAUSES OF RAISED ICP
Intracranial causes (primary)
Increase brain volume
 Space occupying lesion
Tumor abscess hematoma
 Cerebral edema
 Meningitis
 Encephalitis
Increased CSF Volume
Hydrocephalus
Choroid papilloma
Increased Blood volume
Venous sinus thrombosis
Meningitis Encephalitis

Benign Intracranial hypelension

Extra cranial (Secondary)
Respiratory failure
Hepatic failure
Heart failure
Hypertensive encephalopathy
Hyper thermia
RYE Syndrome
 RAISED INTRACRANIAL PRESSURE
• Classical Symptoms
1. Headache
2. Vomiting
3. Impair mental abilities confusion
Classical Signs
1. Bulging Fontanelle
2. Papilloedema
3. Venous pulsation
4. (All the sings are absent in acutely raised ICP)
CLINICAL FEATURE OF INCREASED ICP

In Infants In Children
Bulging fontanelle Diplopia
Failure to thrive Headache
Impaired upward Gaze Mental changes
(setting sun sign ) Vomiting
Large head Papilledema
Prominent scalp veins
Shrill Cry
BULGING FONTANELLE
SETTING SUN SIGN
PROMINENT SCALP VEINS
SHRILL CRY
DIPLOPIA/ SQUINT
FUNDOSOPY PAPILLARY EDEMA
Normal Papillary edema
SIGN OF RAISED ICP

1. Abnormal occlocephalic reflexes

2. Abnormal posture
3. Abnormal pupillary responses
4. Abnormal breathing pattern
5. Cushing triad
ABNORMAL OCCLOCEPHALIC REFLEXES
ABSENT DOLL’S EYE MOVEMENT
ABNORMAL POSTURE
ABNORMAL PUPILLARY RESPONSES
ABNORMAL PUPILLARY RESPONSES
CHEYNE–STOKES RESPIRATION
INVESTIGATIONS - RAISED ICP
1. Fundosopy
2. X.ray skull
3. CT/ MRI
4. Lumber puncture (excluding mass effect)
5. CBC – CRP – ESR
6. M.P slide/ICT malaria
+
Systemic investigations
FUNDOSOPY PAPILLARY EDEMA
Normal Papillary edema
X.RAY SKULL BEATEN SLIVER APPEARANCE
LUMBER PUNCTURE (EXCLUDING MASS EFFECT)
CT/ MRI 2 3
1
1. Brain abscess
2. Brain hematoma
3. Brain tumor
4. Cerebral edema
5. Hydrocephalus
4 5
GOALS OF TREATMENT

1. Keep the ICP < 20mmHg

2. Maintain CPP above 50mmHg by maintain the MAP
 MANAGEMENT PLAN

1. Secure ABC
2. General measure to reduce the ICP
1. Head positioning
2. Sedation and analgesia
3. temperature control
4. treat hypotension (IV fluids & pressers Drug)
5. Seizure prevention
3. Treatment of the Cause
 MANAGEMENT ALGORITHM
Intracranial hypertension

ABC

Neuroimaging

Availability Neuro Surgery YES

NO

ICP Monitoring General ICSOL-resection

Anti- raised ICP measures hydrocephalus- CSF diversion
intracranial bleed

Head positioning
Sedation and Seizure prevention
Midline 20- Euthermia Normovolemia
analgesia treatment
30Oelevation

persisting intracranial
hypertension

Neuromuscular Mannitol Mild hyperventilation

blockade hypertonic saline PaCO2 30-35 mmHg

Refractory intracranial
hypertension

Barbiturate Moderate Hyperventilation Decompressive

therapy hypothermia PaCO2 25-30 mmHg Craniectomy
THANK YOU