SR NEUROSURGERY SGPGIMS LUCKNOW

1. Management of raised
Intracranial pressure and
related factors
Presenters :Dr. Yashveer Singh
Dr.Arif Rasool
Moderator :Dr.Mohd.Sadik Akhtar
Co-moderators :Dr.M.F.Huda

2. GOAL OF MANAGEMENT
Keep ICP <20 mm Hg.
Keep CPP >70 mm Hg.
 Avoid CCP < 50 mmHg.
 So in order to avoid CPP <50 mmHg , it may be best to start
treatment when CPP falls <60 mmHg

3. GENERAL MEASURES
 Head End elevation.
 Keep neck straight and avoid any constriction band.
 Avoid hypotension.
 Control hypertension.
 Avoid Hypoxia (pO2 <60 mmHg).
 Ventilate to normocarbia (Pco2 35-40 mmHg).
 Light Sedation.
 Prophylactic hypothermia.
 NCCT Head

4. ELEVATING HEAD END
 30-45 degree
 Position above heart and prevent
kinking or compression of jugular
vein
 Decrease venous outflow
resistance
 [CSF] Intracrainal compartment
Spinal compartment
 Reduces MAP at Carotid level

5. KEEP NECK STRAIGHT, AVOID ANY
CONSTRICTION BAND
Care should be taken to avoid obstruction of cerebral venous
return by cervical collars or endotracheal tube ties.
 Keep the head maintained in the neutral position.

6. CONTROL BLOOD PRESSURE
Avoid hypotenstion (SBP < 90 mmHg)
 Normalize blood volume
 Use pressors if needed
Control hypertension
 Nitroprusside
 Beta blockers ( labetalol…)
 Avoid overtreatment ( Hypotension)

7. AVOID HYPOXIA (PAO2 <60 mmHg)
 PaO2 shouldn’t fall below 60mmHg and Sat <90%.
 Maintain airways.
 Supplementary oxygen.

8. NORMOCARBIA (PACO2=35-40 mmHg)
 PaCO2 should be maintained around 35-40 mmHg
 CO2 retention leads to vasodilatation leading to increased flow
hence increased ICP.

9. LIGHT SEDATION
 Calm the patient → Restricted movements → Decrease in the
ICP → Controls sudden bursts of rise in ICP.
Codeine =30-60 mm IM q 4hrs
Lorazepam 1-2 mg IV q 4-6 hrs

10. PROPHYLACTIC HYPOTHERMIA
 Controversial.
 Decreased metabolic demand for O2 (CMRO2).
 32-35 degree centigrade.
 > 48 hrs

11. SPECIFIC MEASURES FOR
CONTROL OF RAISED
INTRACRANIAL HYPERTENSION
 Loss of previously controlled ICP.
 Patients not improving clinically.
 Patient is deteriorating.

12.  Heavy sedation.
 Drainage of CSF.
 Osmotic therapy
Mannitol
Hypertonic saline
Furosemide
 Hyperventilation.
 EEG

13. HEAVY SEDATION
 When patient is agitated.
 To blunt the elevation of ICP that occur with certain maneuvers.
Drugs:
MgSO4= 2-4 mg/hr IV.
Fentanyl= 2-5 µg/kg/hr IV.
Sufentanil= 10-30 µg test dose f/b 0.05-2 µg/kg/hr IV.
Propofol drip= 0.5mg/kg test dose f/b 20-70 pg/kg/min IV.
Low dose pentabarbitral=100 mg IV q 4hrs.
Vecuronium= 8-10 mg IV q 2-3 hrs.

14. CSF Drainage
 In conditions where intracranial catheter
is placed CSF can be drained out in
controlled manner to reduce intracranial
pressure.
 75 ml of CSF every 8 hrs should be
drained.
(450-700 ml CSF per day in patients where
none of the CSF is absorbed)
 Drip chamber is at ≤ 10 cm above EAC.

15. OSMOTIC THERAPY
 Mannitol.
 Furosemide.
 Hypertonic saline.

16. MANNITOL
Indications
 Sign of trans-tentorial herniation.
 Progressive neurological deterioration.

17. MANNITOL-MECHANISM
1. Lower ICP
 Plasma expansion reduce hematocrit Increase CBF
and O2 delivery.
ICP decreased with in few minutes (CPP< 70 mmHg).
 Increased serum tonicity Draw edema fluid from cerebral
parenchyma’
Decreased ICP in 15-30 minutes and effect last for 1.5-6 hrs.

18. 2. Supports microcirculation by improving blood rheology
3. Free radical scavenging.
Dose= 0.25-1 gm/kg body weight bolus over <20 minutes then
0.25 mg/kg over 20 minutes q 6hrs.

19. CAUTIONS
 Open ,cross BBB and may draw fluid in to CNS.
 Cortocosteroids+Phenytoin+Mannitol NKH.
 Excessively vigorous bolus HTN If autoregulation
defective ↑CBF and may promote herniation.
 High dose risk of renal failure.

20. FUROSEMIDE
 Increased serum tonicity ↓ Cerebral edema ↓
ICP.
 Slow the production of CSF.
 Dose= 10-20 mg IV q 6hrs.
 Hold serum osmolarity >320 mOsm/L.

21. HYPERTONIC SALINE(HS)
 May reduce ICP in patients refractory to mannitol.
Dose = 3% saline at 25-50 ml/hr IV continuous infusion
(Peripheral line).
= 7.5-23.4% saline must be given through a central line.
 HS should be discontinued after 72 hrs to avoid rebound
edema.
 Serum osmolarity >320 mOsmol/L.
 No improvement in outcome over mannitol has been
demostrated.

22. HYPERVENTILATION(HPV)
 HPV ↓ PaCO2 Cerebral vasoconstriction
↓CBF Shift blood from normal area to area of
decreased blood flow
↓CBV
↓ICP Focal ischemia in area with preserved
blood flow

23. GUIDELINE FOR HPV
1. In the absence of sign of intra-cranial hypertension, chronic
prolonged HPV ( PaCO2 ≤ 25 mmHg) should be avoided.
2. Prophylactic HPV ( ≤ 25 mmHg ) is not recommended.
3. HPV for brief periods ( minutes)
 Prior to insertion of ICP monitor (Sign of raised ICP).
 After insertion of monitor (Sudden ↑ ICP and/or acute
neurological deterioration).

24. 4. HPV for longer period
 Raised ICP not responded to Sedation, paralysis, CSF drainage
and osmotic diuretics.
5. HPV may be appropriate for raised ICP resulting from
hyperemia.

25. Recommendation for PaCO2 following head trauma
PaCO2 ( mmHg)
• 35-40
• 30-35
• 25-30
• <25
Description
• Normocarbia, use routinely
• Hyperventilation.
• Augmented
hyperventilation.
• Aggressive hyperventilation

26. HPV MUST BE WEANED SLOWLY
 Reducing PaCO2 from 35-29 mmHg lowers ICP 25-30%
 Onset of action=30 sec.
 Peak= 8 minutes.
 Effect may be blunted by = 1 hr.
 After which it is difficult to return normocarbia without
rebound elevation of ICP.

27. CAVEATS OF HPV
 HPV should be avoided during first 5 days after Head trauma
( specially first 24 hrs).
 Do not use prophylactically.
 If documented raised ICP is un-responsive to other measures,
hyperventilate only to PaCO2=30-35 mmHg.
 If prolonged HPV to PaCO2=25-30 mmHg is deemed
necessary, consider monitoring SjVO2,CBF to rule-out
cerebral ischemia

28. SURGICAL TREATMENT
 Any subdural or epidural hematoma larger than ≈ 1 cm
maximal thickness should be removed.
 In cases of contusion showing progressive deterioration the
contused parts need to be surgically removed

29. EDH
Surgical indications:
 EDH > 30 cc (regardless of
GCS).
 It is strongly recomended
that patient of acute EDH
with GCS <9 with
Anisocoria undergo urgent
surgical evacuation.

30. SDH
Evacuated regardless of GCS:
 Acute SDH Thickness
>10mm.
 MLS > 5mm (on CT Scan).
Acute SDH with Thickness <
10mm and MLS < 5 mm
should undergo surgical
evacuation if:
 GCS drops by ≥ 2 point
from the time of injury to
admission.
 Pupil are asymetric or fixed
and dilated.
 ICP>20 mmHg.

31. Chronic SDH surgical evacuation of hematoma
indicated if
 Focal deficit, mental status changes
 Maximal thickness >1 cm

32. Chronic SDH
Surgical evacuation of
hematoma indicated if
 Focal deficit, mental
status changes
 Maximal thickness >1
cm

33. Traumatic posterior fossa mass
lesions
 Symptomatic posterior fossa mass lesions or those with
mass effect on CT Scan should be surgically removed.
 Most parenchymal hemorrhage managed non-surgically
were < 3cm in diameters

34. Hemorrhagic contusion
 Progressive neurological deterioration
referable to traumatic intra-cerebral
hemorrhage, medically refractory IC-HTN
or sign of mass effect on CT Scan.
 Traumatic intra-cerebral hemorrhege
volume> 50 cc
 GCS = 6-8 with frontal or temporal
traumatic intra-cerebral volume > 20cc
with MLS ≥ 5mm and or compressed
basal cisterns on CT Scan

35. Traumatic cerebral edema
 Decompressive craniectomy with in 48 hr of
injury for patient with diffuse, medically
refractory post traumatic cerebral edema
associated with IC-HTN.
 Decompressive craniectomy for patients with
refractory IC-HTN and diffuse parenchymal
injury and radiographic evidence for
impending trans-tentorial herniation

36. DECOMPRESSIVE
CRANIECTOMY
• Removal of a large area of
skull to increase the potential
volume of the cranial cavity
• Control raised ICP
• Improve cerebral perfusion
pressure
• Cerebral blood flow
• Control brain edema

37. SHUNTS
1. V-P Shunt
2. V-A Shunt
3. Torkildsen shunt
4. Lumboperitoneal
5. Cyst or subdural shunt
6. Miscellaneous shunt
Pleural space
Gall bladder
Ureter and Urinary blader

38. SUPPORTIVE TREATMENT
 Prophylaxis against ulcer: Antacids/ H2 blockers
:Ranitidine 50mg IV q 8hr.
 IV Fluids: NS+20meq/L.
:Avoid hypotonic solutions (RL).
 Arterial line for B.P. monitoring and frequent ABG.
 Aggressive control of fever.
 CVP line or peripheral arterial line if high dose of mannitol are
needed.
 Glycemic control, neither hypo nor hyperglymia should be
allowed as both of them are detrimental to brain parenchyma.

39. STEPS RATIONALE
Head End elevation. 30-45 degree
Decrease venous outflow resistance
[CSF] Intracrainal compartment to Spinal compartment
Keep neck straight and avoid any constriction band Keep the head maintained in the neutral position
Avoid hypotension Normalize blood volume,Use pressors if needed
Control hypertension. Nitroprusside ,Beta blockers ( labetalol),Avoid overtreatment
( Hypotension)
Avoid Hypoxia (pO2 <60 mmHg). PaO2 shouldn’t fall below 60mmHg and Sat <90%.
Ventilate to normocarbia (Pco2 35-40 mmHg). PaCO2 should be maintained around 35-40 mmHg
Light Sedation. Codeine =30-60 mm IM 4hrs,Lorazepam 1-2 mg IV 4-6 hrs
Prophylactic hypothermia Controversial.,Decreased demand for O2 (CMRO2).
Summary (General measures )

40. Summary (Specific measures )
STEPS RATIONALE
Heavy sedation. When patient is agitated,To blunt the elevation of ICP that
occur with certain maneuvers.
Drainage of CSF Reduce intracranial pressure.,75 ml of CSF every 8 hrs
should be drained,450-700 ml CSF per day in patients where
none of the CSF is absorbed)
Osmotic therapy Lower ICP, Increase CBF and O2 delivery.
Decrease cerebral edema Slow the production of
CSF.
Hyperventilation. HPV ↓ PaCO2 Cerebral vasoconstriction
EEG
Decompresive craniectomy