The pressure-volume relationship
between ICP, volume of CSF, blood,
and brain tissue, and cerebral
perfusion pressure (CPP) is known as
the Monro-Kellie doctrine or the Monro-
Kellie hypothesis.
2
The Monro-Kellie hypothesis
The Monro-Kellie hypothesis states that
the cranial compartment is
incompressible, and the volume inside
the cranium is a fixed volume.
The cranium and its constituents (blood,
CSF, and brain tissue) create a state of
volume equilibrium, such that any
increase in volume of one of the cranial
constituents must be compensated by a 3
INCREASED ICP is a rise in the pressure
inside the skull that can result from or
cause brain injury.
Or
It is a life threatening situation that
results from an increase in any or all of
the 3 components (brain tissue, blood
and CSF) of the skull.
4
Causes of increased ICP include a rise in
cerebrospinal fluid pressure, increased pressure
within the brain matter, bleeding into the brain or
fluid around the brain, or swelling within the
brain matter itself.
5
Any lesion that increases one or
more of the intracranial content is
called a space occupying lesion.
Cerebral edema is one of the
major cause.
Conditions associated with cerebral
edema are
Mass lesion
Head injury
Brain inflammation - Encephalitis,
Meningitis
Aneurysm rupture
6
Hydrocephalus
Bleeding in to the brain or
spinal cord
Status epilepticus -a single
epileptic seizure lasting more
than five minutes or two or
more seizures within a five
minute period
Stroke
Lead and arsenic intoxication
Reye’s syndrome disorder 7
Increased ICP from any cause decreases cerebral perfusion,
stimulates further swelling (edema), and shifts brain tissue
through openings in the rigid dura, resulting in brain
herniation a frequently fatal event.
8
Cerebral blood flow (CBF) is the amount
of blood in milliliters passing through
100g of brain tissue in 1 min
Normally CBF is approximately 50 mL
per minute per 100 g of brain tissue
White matter has a slower blood flow (25
ml/min/100g brain tissue)
Gray matter -75ml/min/100gm brain
tissue
9
The blood flow to the brain is that
much critical because the brain
requires a 20% of oxygen and 25% of
glucose
Inadequate perfusion leads to increase
CO2 concentration
10
Fig. 55-3
Behavior changes
Decreased consciousness, Lethargy,
Seizures, back pain.
Vomiting – non projectile and without nausea
Headache - The headache is classically a
morning headache which may wake them
from sleep. The headache is worse on
coughing / sneezing / bending, and
progressively worsens over time
Neurological symptoms, including
weakness, numbness, eye movement
problems, and double vision
12
Occular problems
Compression of occulomotor nerve
results in -
Dilation of pupil
Sluggish or no response to light
Inability to move the eye upward
Ptosis of the eye lid
Papilledema (swelling of optic disc) -it
may lead to visual disturbances, and
eventually blindness.
13
Changes in vitals – increased BP and altered
respiration
If brain tissues displaced - Cushing's triad
involves an increased systolic blood
pressure, bradycardia, and an abnormal
respiratory pattern.
Cheyne–Stokes respiration, in which
breathing is rapid for a period and then
absent for a period
14
Altered Motor function – hemiparesis or hemiplegia
Decorticate posture or decorticate response
Flexion of arms, wrist and fingers with adduction in
upper extremity
Extension, internal rotation and plantar flexion in
lower extremity
15
Decerebrate posture/ decerebrate responses
All four extremities in rigid extension with hyper
pronation of forearm , adduction of upper extremity,
flexion of wrist with plantar flexion of feet
16
Opisthotonic posturing – a muslce spasm
causing the back to be arched to the head
retracted, with great rigidity of the muscle of
the neck and back.
17
Restlessness (without apparent cause), confusion,
or increasing drowsiness
As ICP increases, the patient becomes stuporous,
reacting only to loud auditory or painful stimuli
In severe increase, exceeds 40-50mm hg -
comatose
When the coma is profound, death is inevitable.
18
History and Physical examination
Vital sign, neurological assessment
Skull, chest and spinal x ray
cerebral angiography, computed tomography (CT)
scanning, or magnetic resonance imaging (MRI).
PET SCAN, EEG, ECG
Transcranial Doppler studies provide information
about cerebral blood flow.
Lumbar puncture is avoided in patients with
increased ICP because the sudden release of
pressure can cause the brain to herniate.
19
CBC
Coagulation profile
Electrolytes, ABG’S, toxicology screen
CSF analysis for protein, cells, glucose
20
ICP MEASUREMENTS
Intracranial pressure monitoring is performed by inserting a catheter into the
head with a sensing device to monitor the pressure around the brain.
21
Location Product
Ventricular catheter with
drainage
Parenchymal, Epidural
Codman, Camino
Subarachnoid, Subdural
Bolt system
Ventriculostomy –
gold standard Advantages
Directly measure
procedure
A catheter is the pressure with
inserted into the in the ventricle
Facilitate removal
lateral ventricle
using a closed and sampling of
system. CSF
The 3 way stopcock Allows intra
is opened to allow ventricular drug
CSF to flow into the administration
24
25
HOB elevated 30° ↑ venous drainage
Head midline ↑ venous drainage
No jugular catheters prevent venous
obstruction
Normothermia avoid ↑ metabolism
Medical Management
a) Maintaining oxygenation
b) Invasive ICP monitoring
c) Decreasing cerebral edema
d) Maintaining cerebral perfusion
e) Lowering CSF volume
f) Controlling fever
g) Reducing metabolic demands
27
Increased ICP is a true emergency and must be treated
immediately through:
a. Maintaining oxygenation:
Intubation and mechanical ventilation
ABG analysis
Elevation of head of the bed to 30 degree with head in a
neutral position
b. Invasive monitoring of ICP
to identify increased pressure
the degree of elevation
to initiate appropriate treatment
to provide access to CSF for sampling and drainage
to evaluate the effectiveness of treatment.
28
c. Decreasing cerebral edema:
Osmotic diuretics (mannitol) - given to dehydrate the brain
tissue and reduce cerebral edema. They reduce the volume of
brain and extracellular fluid
Loop diuretics (frusemide)
Cortico steroids (dexamethasone) – help to reduce cerebral
edema when a brain tumor is the cause of increased ICP.
29
d. Maintaining cerebral perfusion:
The cardiac output may be manipulated to provide adequate
perfusion to the brain.
Inotropic agents such as dobutamine hydrochloride are used.
A lower cerebral perfusion pressure indicates that the cardiac
output is insufficient to maintain adequate cerebral perfusion.
Cerebral perfusion pressure (CPP) is defined as the
difference between mean arterial and intracranial pressures.
Mean arterial pressure is the diastolic pressure plus one
third of the pulse pressure (difference between the systolic
and diastolic). MAP is thus between systolic and diastolic
pressures.
CPP = MAP(70 -110 mmhg) – ICP(0-15 mmhg)
Normal cerebral perfusion pressure is 60-80 mmHg, nearer
diastolic.
30
e. Lowering the volume of CSF and cerebral blood:
CSF drainage is frequently performed because the removal of
CSF with a ventriculostomy drain may dramatically reduce
ICP and restore cerebral perfusion pressure.
f. Controlling fever:
Preventing a temperature elevation is critical because fever
increases cerebral metabolism.
Antipyretics
Cold applications
31
g. Reducing metabolic demands:
Barbiturates (sedatives) -Cellular metabolic demands can be
reduced (high doses).
Barbiturates induce coma, lower ICP and decrease mortality.
32
Drug therapy (drugs used in
INCREASED ICP)
Osmotic diuretics
Loop diuretics
Corticosteroids
Barbiturates
Ionotropic drugs
Sedatives
Analgesics
Antiseizure drugs
33
Nutritional therapy
Nutritional replacements should
begins within 3 days after injury.
Patient is in hypermetabolic and
hypercatabolic state
Need for glucose
Keep patient normovolemic
IV 0.45% or 0.9% sodium chloride
34
35
Opening in the cranium for access to brain
As raised ICP's may be caused by the presence
of a mass, removal of this via craniotomy will
decrease raised ICP's.
A drastic treatment for increased ICP
is decompressive craniectomy, in which a
part of the skull is removed and the dura
mater is expanded to allow the brain to swell
without crushing it or causing herniation.
The section of bone removed, known as a bone
flap, can be stored in the patient's abdomen or
thigh and resited back to complete the skull.
Alternatively a synthetic material may be used
to replace the removed bone section 36
37
Methods are provided for preserving
and restoring cranial bone flaps.
In one aspect, the method to preserve a
cranial bone flap includes cleaning a
cranial bone flap, washing the cranial
bone flap with a sterile saline solution
including gentamycin, and washing the
bone with a sterile saline solution
including vancomycin.
The cranial bone flap may be dried,
wrapped, and packaged before being
stored in a freezer.
38
The fixing method may include removing
the preserved cranial bone flap from a
freezer and unwrapping the preserved
cranial bone flap from any wrappings.
The preserved cranial bone flap may be
washed with a sterile saline solution
including gentamycin and a sterile saline
solution including vancomycin.
39
Assessment:
Obtain a history of events leading to the present illness
The neurologic examination should include an evaluation
of mental status, level of consciousness (LOC), cranial nerve
function, cerebellar function (balance and coordination),
reflexes, and motor and sensory function. Assessment of
LOC includes eye opening; verbal and motor responses;
pupils (size, equality, reaction to light).
Glasgow Coma Scale 40
Eye opening response Spontaneous 4
To voice 3
To pain 2
None 1
Best verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response Obeys command 6
Localizes pain 5
Withdraws 4
Flexion (decorticate) 3
Extension (decerebrate) 2
None 1
Total 15
41
Nursing diagnoses:
Increased intracranial pressure assosiated with head injury
Ineffective airway clearance related to diminished
protective reflexes (cough, gag)
Ineffective breathing patterns related to neurologic
dysfunction
Ineffective cerebral tissue perfusion related to the effects of
increased ICP
Risk for fluid and electrolyte imbalance related to osmotic
diuretic therapy
Risk for physiologic injury related to seizures
Risk for infection related to altered nutrition
42
Nursing Interventions:
Maintaining patent airway.
Assess the patency of the airway.
Suction with care- secretions obstructing the airway, because transient
elevations of ICP occur with suctioning.
The patient is hyperoxygenated before and after suctioning to maintain
adequate oxygenation.
Discourage coughing because it increases ICP.
Auscultate the lung fields at least every 8 hours to determine the presence
of abnormal breath sounds.
Elevate the head of the bed may aid in clearing secretions as well as
improving venous drainage of the brain.
43
Achieving an adequate breathing pattern
Monitor the patient constantly for respiratory
irregularities. This includes Cheyne-Stokes respirations
(alternating periods of hyperpnea and apnea)
44
Monitor PaCO2 (normal range 35 to 45 mm Hg) if
hyperventilation therapy has been decided to reduce ICP
Maintain a neurologic observation record. Repeated
assessments of the patient are made frequently to
immediately note improvement or deterioration.
45
Optimising cerebral tissue perfusion
Maintain head alignment and elevate head of bed 30 degrees.
The rationale is that hyperextension, rotation, or hyperflexion of
the neck causes decreased venous return.
Avoid extreme hip flexion as this increases intra-abdominal and
intrathoracic pressures, leading to rise in ICP.
Avoid the Valsalva maneuver (straining at stool) as it raises ICP.
Administer stool softeners as prescribed. If appropriate, provide
high fiber diet.
46
When moving or being turned in bed, instruct the patient to exhale
to avoid the Valsalva maneuver.
If the patient is on mechanical ventilation, preoxygenate and
hyperventilate him, before suction, using 100% oxygen on the
ventilator. Suctioning should not last longer than 15 seconds.
Avoid activities that raise ICP if possible. Space nursing
interventions; this may prevent transient increases in ICP.
47
During nursing interventions, the ICP should not rise above
25 mm Hg and should return to baseline levels within 5
minutes.
Patients with the potential for a significant increase in ICP
should receive sedation or “paralyzation” before initiation of
many nursing activities.
Avoid emotional stress, disturbances from sleep, and
environmental stimuli (noise, conversation).
Isometric muscle contractions (Pushing against an immovable
wall) are also contraindicated because they raise the systemic
blood pressure and hence the ICP.
48
1. Inadequate cerebral perfusion
2. Cerebral herniation
Transforaminal herniation – occurs when
the brainstem is forced downward
through the foramen magnum
Uncal herniation – occurs when uncal
portion of the temporal lobes shift over
the edge of the tentorium cerebelli
Cingulate herniation –brain is forced
under the falx-cerebri that separates the
cerebral hemispheres
49
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