This document discusses intracranial physiology and the monitoring of intracranial pressure (ICP). It explains that ICP monitoring allows for early identification of raised ICP and informed treatment to maintain an optimal cerebral perfusion pressure. ICP should be monitored in patients with acute brain injury, traumatic brain injury with a low Glasgow Coma Scale, and certain non-traumatic conditions involving cerebral edema. ICP can be monitored via intraventricular or intraparenchymal catheters, though complications may occur. General management aims to control factors that influence ICP through ventilation, fluids, osmotherapy, and in severe cases, induced hypothermia or barbiturates. The goal is to maintain ICP below

1. Overview
Intracranial Physiology
Why should monitor ICP
How to monitor ICP
Who can monitor ICP
Management
?

2. Intracranial Physiology
Monro-Kellie doctrine
Total volume within the skull remains constant
Brain tissue compartments (≈80%)
Blood (≈10%)
Cerebrospinal fluid (≈10%)
Autoregulation
CBF is kept constant by vasoconstriction and/or vasodilatation
cascades of the cerebral vessels.
Lundberg N. Acta Psychiatr Scand Suppl 1960

3. Intracranial volume and ICP
Rodriguez-Boto G et al. Neurologia. 2015

4. Why should monitor ICP ?
 Raised ICP is often seen in patients with acute brain injury
- Neurologic and Nonneurologic etiologies
 Unless diagnosed early and treated promptly – poor outcome
- Decreased cerebral perfusion
- Global hypoxic-ischemic injury
- Herniation of brain tissue
Latorre et al. Neurologist 2009

5. Why should monitor ICP ?
 ICP monitoring
- Allows early identification of raised ICP
- Helps in setting more informed goals for Rx
- CPP guided therapy: allows clear cut end points
- It prevents blind treatment of ICP
- Allows titration and modification of therapy
- Improvement of outcomes
Singhi S et al. Pediatr Crit Care Med 2015
Latorre et al. Neurologist 2009

6. Why should monitor ICP ? - Evidence
many more . . .

7. When should monitor ICP ?
Non-traumatic
- Acute CNS infections
- Acute hepatic encephalopathy,
- Refractory hypertensive encephalopathy
- Metabolic/Toxic Encephalopathy with radiologic
evidence of cerebral edema
- Ischemia: Hemispheric Infarction > 50% MCA territory
- Intracranial Hemorrhage
Traumatic brain injury (TBI)
 All patients with an m-GCS ≤ 8
Singhi S et al. Pediatr Crit Care Med. 2015
Stocchetti N et al. N Engl J Med. 2014
Latorre JG et al. Neurologist. 2009

8. How to monitor ICP ? (Types)

9. How to monitor ICP ? Which Types ?
Intra-ventricular transducer Intra-parenchymal transducer
 Accurate measurement
 Periodic re-zeroing
 To withdraw CSF
 Instillation of medications
 Need for cannulation
 Blockage by blood clots
 CSF leaks
 Risk of infection
Ease of placement
Not occluded by debris
Accurate ICP values
Sharp and distinct waveforms
Mechanical failure
Inability to recalibrate in situ
Unable to drain the CSF
Expensive
- Singhi S, Kumar R et al. Pediatr Crit Care Med 2015
-Andrea L et al. Curr Opin Anesthesiol 2011

10. How to monitor ICP ? (Personal)
Concerns by an Pediatric intensivist
 Bleeding [0% to 10%]
 Technical limitation
 Neurosurgical procedure
 Complications
Influenced
 Type of transducer & catheter
 Presence of coagulopathy
 Technical skills

11. How to monitor ICP ? (Personal)

12. How to monitor ICP ? (Personal)
 265 intracranial pressure catheters were placed in 259 patients
 Median age of patients was 4.8 years, youngest being 6 weeks
 Total duration of ICP monitoring was 31,710 hours
 Complications: 3.5%
 0.28 per 1,000 hours of intracranial pressure monitoring
[ [infection-related 0.09 and non-infection related 0.19]
Pediatr Crit Care Med 2015

13. How to monitor ICP ? (Prerequisite)
“Normal” Coagulation Parameters
 Use of blood products to normalize clotting parameters
Delay the ICP monitoring
It is not supported by available evidence
-Andrea L et al. Curr Opin Anesthesiol 2011
Singhi S, Kumar R et al. Pediatr Crit Care Med 2015
 A platelet count of 100,000
 Prothrombin index of minimum 75%
 INR of less than 1.2
14.7% - not achieved the prerequisite – No bleeding complications

14. How to monitor ICP ? (Confirmation)

15. Management : ICP Monitoring in Place
General measures and First tier therapy
 Head in neutral position, 30° elevation.
 Ensure oxygenation- Normoxia (PaO2>60 mmHg, SpO2>92%)
 Ensure adequate circulating volume- Normovolemia
 Maintain normal BP
 Ventilation to achieve PaCO2 ≈35 mmHg

16. Management : ICP Monitoring in Place
General measures and First tier therapy
 Osmotic diuretic- Mannitol 0.25–0.50 /kg i.v. over 20 min,
repeat S.O.S or Hypertonic (3%) saline infusion: 10 ml/kg
bolus, followed by 0.1 ml−1.0 ml/kg h infusion.
 Dexamethasone - 1–2 mg/kg i.v. Q 6 h—cytotoxic cerebral
edema (brain abscess, granuloma, tumor)
 CSF drainage- Obstructive hydrocephalus
 Prevent all events that increase ICP
- Fever / hypothermia, pain- adequate sedation–
analgesia, seizures- anticonvulsant, loud noise,
invasive stimuli.

17. Management : ICP Monitoring in Place
Second tier therapy
 Hyperventilation (PaCO2 30–35 mmHg)
 Barbiturates coma- Thiopental or pentobarbital
 Moderate hypothermia(32–34°C)
Third tier therapy
 Decompressive craniectomy or temporal lobectomy
 Profound hyperventilation to PaCO2>25 < 30 mm Hg (use
transiently)

18. Targets of therapy
ICP
 Supportive therapies
 Osmotherapy
 Other measures
MABP
 Fluid bolus
 Vasoactive drugs
Target to maintain
CPP ≥ 60 mmHg
Target to maintain
ICP <20 mmHg
- Kumar R et al. Crit Care Med 2014

19. Points to note
 Crucial step
Identifying patients at risk of developing raised ICP
 ICP monitoring is advocated for patients at high risk of
raised ICP especially for those with a worsening
examination.
 Pediatric intensivists can safely and successfully perform
burr holes at bedside for ICP monitoring
 CPP-based management (target CPP ≥ 60 mm Hg) is
advantage over ICP-based management

20. ‘‘Courage is the first of human qualities because
it is the quality which guarantees all others’’
- Aristotle
thank you