Cerebral Blood Flow
& ICP
Vessels
Capillaries
• Tight junctions-endothelial cells
surrounded by end feet of astrocytes
- gaps
• In choroid plexus
endothelium-gaps
epithelium – tight junctions
Innervation
• Postganglionic sympathetic
sup. cervical ganglion
• Cholinergic neurons
sphenopalatine ganglion
• Sensory nerves
Trigeminal ganglion
Normal values
• Weight 2% 1.2 – 1.4 kg
• C.O 15% 100 – 150 ml
• CBF pre mature and infants 40-42ml/100g
adult 50
infants & children
6/12 -3 yrs 90
3yrs -12 yrs 100
ctd
• CMRO2-20% total O2 consumption
neonate 2.3ml/100g/mt
children 5.2ml/100g/mt
adult 3.5
BBB
• Tight junctions of the
capillaries bbb
choroid plexus bcb
• Carrier mediated transport
• Transport out of the brain is more due to bulk flow
in arachnoid villi
• H2O, CO2, O2,lipid soluble steroids -freely
• Proteins and protein bound molecules –less
• H+ & HCO3- ions slow
Control of CBF
• Autoregulation- myogenic
due to vasogenic discharge
• Autoreglatory level
MABP 65-140
• right chronic hypertension
Intense sympathetic discharge
stress
Short plateau – hydralazine, captopril
• left hypercarbia
• Vasomotor paralysis-trauma, brain retraction,high ICP, tumours,
ischaemia, seizures
•
Disruption
• Head trauma
• Lactic acidosis
• Tumour
• Hypercarbia
• Potent inhalational agents
Flow metabolic coupling
• Instantaneous
• H,K, Ca, adenosine, NO,phosphplipids
metabolites
• Disruption – acid-base disturbances, inhaled
anaesthetics, trauma, pain and anxiety
• Via NO mechanisms
Neurogenic
• Dominant sympathetic discharge
• Increased symp. discharge can reduce blood
flow by 60%
• H’gic hypotension less tolerated than
pharmocologically induced hypotension
• May provide on-off switch for flow-metabolic
and autoregulatory phenomena
• A rapid response
CO2
• 1 mmHg rise—CBF 2ml/100g/mt rise
CBV 0.04 ml/100g
• Mediated via H+
• Attenuated by severe haemodilution
severe hypotension
old age
SAH
ischaemic brain injury
severe traumatic brain injury
• Neonate – not well developed
O2
• Dilatation-<50 mmHg
doubled at <30mm Hg
• 100 o2 Reduces CBF by 10-15%
• Haemodilution increases CBF
ICP
• Closed cavity
• Non compressible
• Brain tissue 80%
• CSF 8%
• Blood vessels 12%
• NORMAL-15 mmHg
• HIGH- Constantly above 20mmHg
Production
• 550ml/day
choroid plexus 50-70%
around vessels
Ventricular wall
• Function-protective
CSF absorption
• Arachnoid villi and veins around spinal n.
Bulk flow- at a P of 112 CSF p
stopped at 68
Mainly P dependent
• Diffusion
When does the intracranial P rise?
• Rise in VOLUME brain tissue (+oedema)
oedema- 1. vasogenic –leaky
BBB
2. high CSF P
.3. Intracellular- impaired ionic pumps
• 1& 2 cause an increase in interstitial
fluid
ctd
• Blood volume
• CSF volume
• Anaesthetist could help in controlling
tissue volume
blood volume
Compensation
• Acute rise
• Chronic rise
Ctd
• Reflex response
1. Reflex reduction in cerebro vascular R
(due to auto regulators)
2. Systemic Hypertension
3. Reflex bradycardia
Compliance of the Brain
• V difference/ P difference
• 1 ml saline injected >5 mmHg rise abnormal
<2 normal
Treatment
• Hyperventilation
• Diuretics/ osmotic agents
• Facilitation of venous flow
• Barbiturates
• Decompressive surgical procedures
