Increased intracranial pressure

1. INCREASED
INTRACRANIAL PRESSURE
PRESENTED BY:
MISS.SHWETA SHARMA
M.SC. NURSING 2ND YEAR
ROLL NO. 5
AIIMS, JODHPUR

2. INTRODUCTION
• The central nervous system contents,
including brain, spinal cord, blood, and
cerebrospinal fluid (CSF), are encased in a
noncompliant skull and vertebral canal,
constituting a nearly incompressible system.
• In a normal adult, the skull encloses a total
volume of 1450 mL: 1300 mL of brain, 65 mL
of CSF, and 110 mL of blood. ICP is usually
measured in the lateral ventricles; normal ICP
is 10 to 20 mm Hg.

3. MONROE-KELLIE HYPOTHESIS

4. • The Monroe-kellie hypothesis states that
because of the limited space for expansion
within the skull, an increase in any one of the
components causes a change in the volume
of the others.

5. Cerebral Perfusion Pressure
• CPP = MAP - ICP (Normal = 70 - 100 mm Hg)
• MAP = 1/3 Systolic + 2/3 Diastolic BP
CEREBRAL BLOOD FLOW (CBF)
• Flow = Pressure/Resistance
• Cerebral Blood Flow = Cerebral Perfusion Pressure (systemic
pressure – intracranial pressure)/Cerebral Vascular Resistance

6. • Because brain tissue has limited space to
change, compensation typically is
accomplished by displacing or shifting
CSF, increasing the absorption of CSF, or
decreasing cerebral blood volume.
Without such changes, ICP will begin to
rise.
• Under normal circumstances, minor
changes in blood volume and CSF volume
occur constantly due to alterations in
intrathoracic pressure (coughing,
sneezing, straining), posture, blood
pressure, and systemic oxygen and
carbon dioxide levels.

7. Increased ICP is defined as a sustained
elevation in pressure above 20mm of Hg.

8. EPIDEMIOLOGY
• 90% of affected individuals are women of childbearing age.
• Individuals with chronic hypertension or obesity are also at
an increased risk for developing intracranial hypertension.
• A frequency of occurrence has been established to be 1.0 per
100,000 in the general population, 1.6 to 3.5 per 100,000 in
women, and 7.9 to 20 per 100,000 in women who are
overweight.

9. INTERRELATIONSHIPS

10. ETIOLOGY
Primary or Intracranial Causes
• Trauma (epidural hematoma, subdural
hematoma, intracerebral haemorrhage or
contusions)
• Brain tumours
• Stroke
• Nontraumatic intracerebral Haemorrhage
(aneurysm rupture)
• Idiopathic or benign intracranial hypertension
• Hydrocephalus
• Meningitis

11. Secondary or Extracranial Causes
• Hypoventilation (hypoxia or
hypercarbia)
• Hypertension
• Airway obstruction
• Metabolic (drug-induced)
• Seizures
• Hyperpyrexia
• High altitude cerebral oedema

14. 1. Decreased cerebral blood flow
• Increased ICP may significantly reduce cerebral blood flow, resulting
in ischemia and cell death.
• A rise in PaCO2 causes cerebral vasodilatation, leading to increased
cerebral blood flow and increased ICP; a fall in PaCO2 has a
vasoconstrictive effect.
• Decreased venous outflow may also increase cerebral blood
volume, thus raising ICP.

15. 2. Cerebral edema
• Cerebral edema or swelling is defined as an abnormal accumulation
of water or fluid in the intracellular space, extracellular space, or
both, associated with an increase in brain tissue volume.
• As brain tissue swells within the rigid skull, several mechanisms
attempt to compensate for the increasing ICP. These mechanisms
include autoregulation and decreasing the production and flow of
CSF.

16. 3. Cerebral response to increased ICP
• As ICP rises, compensatory mechanisms in the brain work to maintain
blood flow and prevent tissue damage.
• The brain can maintain a steady perfusion pressure when the arterial
systolic blood pressure is 50 to 150 mm Hg and ICP is less than 40 mm
Hg.
• At a certain volume or pressure, the brain’s ability to autoregulate
becomes ineffective and decompensation (ischemia and infarction)
begins. When this occurs, the patient exhibits significant changes in
mental status and vital signs.

17. • The bradycardia, hypertension, and bradypnea associated with this
deterioration are known as Cushing’s triad, a grave sign.
• At this point, herniation of the brain stem and occlusion of the
cerebral blood flow occur if therapeutic intervention is not
initiated. Cessation of cerebral blood flow results in cerebral
ischemia, infarction and brain death.

18. BRAIN SHIFT – TYPES
• Unchecked lateral tentorial herniation leads to central tentorial and
tonsillar herniation, associated with progressive brain stem dysfunction
from midbrain to medulla.

21. • Headache – worse in the morning, aggravated by
stooping and bending.
• Vomiting – occurs with an acute rise in ICP.
• Papilledema – occurs in a proportion of patients
with ↑ΙCP. It is related to CSF obstruction and
does not necessarily occur with brain shift alone.
• Restlessness (without apparent cause),
confusion, or increasing drowsiness
• Stuporous, reacting only to loud auditory or
painful stimuli

22. • When the coma is profound, with
the pupils dilated and fixed and
respirations impaired, death is
usually inevitable.
The earliest sign of increasing ICP is
a change in LOC. Slowing of speech
and delay in response to verbal
suggestions are other early
indicators.

24. ICP monitoring

26. • Lumbar puncture is
avoided in patients
with increased ICP
because the sudden
release of pressure
can cause the brain to
herniate.

27. COMPLICATIONS
• Brain stem herniation
• Diabetes insipidus
• Syndrome of inappropriate
antidiuretic hormone (SIADH)
• Seizures
• Stroke
• Death

28. MEDICAL MANAGEMENT
• Invasive monitoring of ICP
• Immediate management to relieve increased ICP - decreasing
cerebral edema, lowering the volume of CSF, or decreasing cerebral
blood volume while maintaining cerebral perfusion.
• Administering osmotic diuretics and corticosteroids
• Restricting fluids and draining CSF
• Controlling fever
• Maintaining systemic blood pressure and oxygenation
• Reducing cellular metabolic demands

29. Monitoring ICP
• The purposes of ICP monitoring are:
to identify increased pressure early in its course (before cerebral
damage occurs)
to quantify the degree of elevation
to initiate appropriate treatment
to provide access to CSF for sampling and drainage
to evaluate the effectiveness of treatment

30. • An intraventricular catheter (ventriculostomy), a subarachnoid bolt,
an epidural or subdural catheter, or a fiberoptic transducer-tipped
catheter placed in the subdural space or the ventricle can be used to
monitor ICP.

31. Complications of ICP monitoring:
• Infection
• Intracranial hemorrhage or haematoma
• CSF Leakage
• Mechanical failure or blockage
• Over drainage of CSF

32. METHODS OF REDUCING INTRACRANIAL
PRESSURE
Mannitol infusion:
• An IV bolus of 100 ml of 20% mannitol infused over 15 minutes
reduces intracranial pressure by establishing an osmotic gradient
between the plasma and brain tissue. This method ‘buys’ time
prior to craniotomy in a patient deteriorating from a mass lesion.
Mannitol is also used 6-hourly for a 24–48-hour period in an
attempt to reduce raised ICP.

33. CSF withdrawal:
• Removal of a few ml of CSF from the ventricle immediately
reduces the intracranial pressure. Within minutes, however, the
pressure will rise and further CSF withdrawal will be required.
• In practice, this method is of limited value, since CSF outflow to
the lumbar theca results in a diminished intracranial CSF volume
and the lateral ventricles are often collapsed. Continuous CSF
drainage may make most advantage of this method.

34. Sedatives: If intracranial pressure fails to respond to standard measures
then sedation may help under carefully controlled conditions.
-Propofol, a short acting anaesthetic agent, reduces intracranial
pressure but causes systemic vasodilatation. If this occurs pressor
agents may be required to prevent a fall in blood pressure and a
reduction in cerebral perfusion.
-Barbiturates (thiopentone) reduce neuronal activity and depress
cerebral metabolism; a fall in energy requirements theoretically
protects ischemic areas.

35. Controlled hyperventilation:
• Bringing the PCo2 down by hyperventilating the sedated or paralyzed
patient causes vasoconstriction. Although this reduces intracranial
pressure, the resultant reduction in cerebral blood flow may
aggravate ischemic brain damage and do more harm than good.
• Maintaining the blood pressure and the cerebral perfusion pressure
(CPP) (>60 mmHg) appears to be as important as lowering
intracranial pressure.

36. • Hypothermia: Cooling to 34°C lowers ICP.
Hypothermia after cardiac arrest with slow rewarming
has been reported to improve outcome.
• Steroids: By stabilising cell membranes, steroids play
an important role in treating patients with oedema
surrounding intracranial tumours. Dexamethasone is
given 4-6 mg every 6 hours.

37. SURGICAL MANAGEMENT

38. • Decompressive craniectomy is
performed on victims of
traumatic brain injury, stroke,
Chiari Malformation, and other
conditions associated with raised
intracranial pressure.
• Resection of intracranial mass
lesions producing elevated ICP.

40. Nursing assessment
• History collection - it may be necessary to obtain this information from
family or friends.
• Neurologic examination - evaluation of mental status, LOC, cranial nerve
function, cerebellar function (balance and coordination), reflexes, and
motor and sensory function.
• Because the patient is critically ill, ongoing assessment will be more
focused, including pupil checks, assessment of selected cranial nerves,
frequent measurements of vital signs and intracranial pressure, and use
of the Glasgow Coma Scale.

41. Nursing diagnosis
Ineffective airway clearance related to diminished protective reflexes
(cough, gag) as evidenced by presence of secretions.
Goal- Patient will maintain a patent airway.
Interventions-
• Assess the airway for patency.
• Secretions obstructing the airway must be suctioned with care, because
transient elevations of ICP occur with suctioning.
• Coughing is discouraged because coughing and straining also increase
ICP.
• The lung fields are auscultated at least every 8 hours to determine the
presence of adventitious sounds or any areas of congestion.
• Elevating the head of the bed may aid in clearing secretions as well as
improving venous drainage of the brain.

42. Ineffective breathing pattern related to neurologic dysfunction
(brain stem compression, structural displacement) as evidenced by
altered respiratory rate.
Goal- Patient will have normalization of respiration.
Interventions-
• Assess the respiratory pattern and monitor constantly for
respiratory irregularities.
• Monitor arterial blood gas values.
• Place patient with proper body alignment for maximum breathing
pattern.
• Suction secretions, as necessary.
• Provide oxygen as prescribed.

43. Ineffective cerebral tissue perfusion related to the effects of increased ICP as
evidenced by reduced saturation.
Goal- Patient will maintain adequate cerebral tissue perfusion through reduction in
ICP.
Interventions-
• Assess and monitor the intracranial pressure.
• The head is kept in a neutral (midline) position, maintained with the use of a
cervical collar if necessary, to promote venous drainage.
• Elevation of the head is maintained at 0 to 30o to aid in venous drainage unless
otherwise prescribed.
• Extreme rotation of the neck and flexion of the neck are avoided because
compression or distortion of the jugular veins increases ICP. Extreme hip flexion is
also avoided because this position causes an increase in intra-abdominal and
intrathoracic pressures, which can produce a rise in ICP.
• The Valsalva maneuver, which can be produced by straining at defecation or even
moving in bed, raises ICP and is to be avoided.

44. Deficient fluid volume related to fluid restriction as evidenced by dry skin and
poor turgor.
Goal- Patient will have restoration of fluid balance.
Interventions-
• Assess the fluid volume by measuring intake and output.
• Monitor skin turgor, mucous membranes, and serum and urine osmolality to
assess fluid status.
• If fluids are given intravenously, ensure that they are administered at a slow to
moderate rate with an intravenous infusion pump to prevent too-rapid
administration and avoid overhydration.
• Monitor vital signs, including blood pressure to assess fluid volume status.
• An indwelling urinary catheter is inserted to permit assessment of renal
function and fluid status.
• Monitor urine output every hour in acute phase, provide oral hygiene and apply
emollient to keep skin moist.

45. Risk for infection related to ICP monitoring system (fibreoptic or intraventricular
catheter).
Goal- Patient will be free from risk of infections.
Interventions-
• Assess the risk factors of infection.
• The dressing over the ventricular catheter must be kept dry because a wet
dressing is conducive to bacterial growth.
• Aseptic technique must be used when managing the system and changing the
ventricular drainage bag.
• The drainage system is also checked for loose connections because they cause
leakage and contamination of the CSF as well as inaccurate readings of ICP.
• Observe the character of the CSF drainage and report observations of increasing
cloudiness or blood.
• Monitor the patient for signs and symptoms of meningitis: fever, chills, nuchal
(neck) rigidity, and increasing or persisting headache.

46. PROGNOSIS
• Sudden increased intracranial pressure is a serious and often
life-threatening condition. Prompt treatment results in better
prognosis.
• If the increased pressure pushes on important brain
structures and blood vessels, it can lead to serious,
permanent problems or even death.

47. PREVENTION
Increase in ICP cannot be prevented, but head injury can be
prevented.
• Always wear a helmet when driving a bike or playing contact
sports.
• Wear seatbelt when driving and keep seat back as far as possible
from the dashboard or the seat in front.
• Always buckle children into a child safety seat.
• Falling at home is a common cause of head injury, especially in
older adults. Avoid falls at home by keeping floors dry and
uncluttered. If necessary, install handrails.

49. Hypertonic saline and mannitol in patients with traumatic brain injury
A systematic review and meta-analysis were done by Shi, Jiamin; Tan, Linhua; Ye,
Jing; Hu, Lei in 2020 to compare the effects of 3% hypertonic saline solution and 20%
mannitol solution on intracranial hypertension. Relevant literatures of randomized
controlled trials comparing 3% hypertonic saline solution with mannitol in reducing
intracranial hypertension from 2010 to October 2019 were collected. As a result, 10
articles that met the inclusion criteria were finally included. A total of 544 patients
were enrolled in the study, 270 in the hypertonic saline group and 274 in the mannitol
group. There was no significant difference in the decrease of intracranial pressure and
the onset time of drug between the 2 groups after intervention. There was a
statistically significant difference between the hypertonic saline group and the
mannitol group in terms of duration of effect in reducing intracranial pressure and
cerebral perfusion pressure after intervention. The study concluded that both 3%
hypertonic saline and mannitol can effectively reduce intracranial pressure, but 3%
hypertonic saline has a more sustained effect on intracranial pressure and can
effectively increase cerebral perfusion pressure.

50. Bedside ultrasonographic assessment of optic nerve sheath diameter as a means
of detecting raised intracranial pressure in neuro-trauma patients: A cross-
sectional study
A cross-sectional study was conducted by Amandeep Kaur, Parshotam L Gautam,
Shruti Sharma, Vikram P Singh, Sarit Sharma in 2020 to determine whether the
bedside sonographic measurement of Optic nerve sheath diameter (ONSD) can
reliably predict elevated ICP in neuro-trauma patients. It is helpful in situations
where imaging of brain or direct ICP monitoring is not available or feasible. All
patients underwent ONSD sonography of the eye and CT scan subsequently. ONSD
of ≥5.0 mm was considered as a benchmark of raised ICP. Mean ONSD of the study
group with ONSD ≥5.0 mm was 5.6 ± 0.3 mm. ONSD was raised in 46% of patients,
more so in patients with low GCS (3-6). The relationship of ONSD with GCS, CT scan
findings, and RTS was highly significant. The sensitivity of the bedside sonographic
measurement ONSD to detect raised ICP was 93.2% and specificity was 91.1% when
compared with CT scan. Positive Predictive Value of the ONSD measurement was
89.1% and the negative predictive value was 94.4%. The study concluded that
ultrasonographic assessment of ONSD is a reliable modality to detect raised ICP in
neurotrauma patients. It can be helpful in the early initiation of treatment of
elevated ICP, thus preventing secondary brain damage.

51. SUMMARY AND CONCLUSION
• As discussed throughout the presentation, learning about
increased intracranial pressure and its management will help
nurses to care for a patient with increased ICP. Nurses can do
assessment of such patient, observe the sign and symptoms,
provide the necessary nursing care and support the patient
psychologically. Nurses can also counsel the patients and their
family.