The document discusses intracranial pressure (ICP), its causes, identification methods, and management strategies. ICP increases when there is decompensation in cranial compartments due to factors like tumors, hydrocephalus, or vascular malformations. It outlines a tiered approach for management ranging from basic neuroprotective measures to advanced interventions like decompressive craniectomy.

1. INTRACRANIAL PRESSURE
DR. DIKSHITA BHATTARAI
MEDICAL OFFICER

2. 1. Relation of intracranial volume and
pressure
2. Causes of intracranial
hypertension
3. Identification of raised intracranial
pressure
4. Monitoring Intracranial pressure
5. Tiered approach in management
of intracranial hypertension
Overview:

3. Components of intracranial cavity

4. MONRO-KELLIE DOCTRINE

5. “Increase in one
brain
compartment,
needs to be
compensated by
another- if it
exceeds
compensation
capacities- ICP is
raised”

6. Causes of raised ICP
● Brain
- Tumors
- Abscesses
- Hematoma
- Cerebral edema
- Encephalitis

7. ● CSF
- Hydrocephalus
- Choroid Plexus Tumors
- Obstruction

8. ● Blood
- Vascular Malformations
- CVST
- Hypoxemia
- Hyperpyrexia
- Elevated CVP (i.e. Heart Failure)

9. Features of Raised ICP

11. Herniation Syndromes

12. CT findings of Raised ICP

13. ICP Monitoring
● Non-invasive-Ocular sonography:
1. Increased nerve sheath diameter (>5.0mm)
2. Discrete, anechoic fluid collection within optic nerve sheath
3. Elevation of optic disc (>6.0mm)
4. Visualization of ipsilateral MCA

14. ● Invasive methods of ICP measurement

15. Tiered approach to management of
ICP
● TIER ZERO (Basic neuroprotective strategies)
- Elevation of head end of bed
- Fever prevention
- Removal of tight tube ties
- Removal of C-spine collar

16. ● TIER ONE
- Increase Analgesia
- Increase Sedation
- Normo-Hypercarbic state (PCO2 35-38mmHg)
- Mannitol or hypertonic saline bolus (upto sodium of 155mmol/L)
- CSF drainage by EVD

17. ● TIER TWO
- Hyperventilate upto 32-35mmHg
- Use neuromuscular paralysis
- Perform MAP challenge - if autoregulation is intact, use
fluids/vasopressors/inotropes to increase CPP to 60-70

18. ● TIER THREE
- Thiopentone coma
- Decompressive Craniectomy
- Therapeutic hypothermia (35C - 36C)

19. Summary
● Increase in one cranial compartment needs to be compensated by another-the
failure of which causes raise in intracranial pressure
● ICP increases as a result in decompensation after increase in any one of the brain,
CSF of Blood compartments in the cranial vault
● Raised ICP manifests as headache, visual disturbances, nausea/vomiting,
convulsions, altered sensorium

20. ● Non-invasive methods of ICP monitoring include Optic nerve sheath measurement
while invasive methods include Ventriculostomy, Epidural transducers, Subdural
bolts and catheters
● Tiered approach to management of Intracranial Hypertension:
1. Tier zero: Basic neuroprotective strategies
2. Tier 1: Osmotic agents, Hypercarbia, Analgesia and Sedation, EVD
3. Tier 2: Hyperventilation, Paralysing agents, MAP challenge
4. Tier 3: Thiopentone coma, Decompressive craniectomy

21. References
https://www.youtube.com/watch?v=K4QexcCqcCU&t=2535s- Principles of
Neurophysiology (Dr. Rebel), University of Kentucky Department of Anesthesiology
Pinto VL, Tadi P, Adeyinka A. Increased intracranial pressure. Nih.gov. Published July
31, 2023. https://www.ncbi.nlm.nih.gov/books/NBK482119/