Tentang Prinsip dan Manajemen Tekanan Intrakranial / ICP

1. Prinsip dan Tatalaksana TIK
Ahmad Muslim Hidayat T (AMU)

2. 7. Tatalaksana TIK

3. Cerebral Blood Flow / Volume
Lindsay, K. W., Bone, I., Fuller, G. and Callander, R. (2011) Neurology and Neurosurgery Illustrated. Fifth. Edinburgh: Churchill Livingstone Inc.

4. INTRACRANIAL PRESSURE
DOKTRIN MONROE-KELLY
“Cranial compartment is incompressible, and the volume
inside the cranium is a fixed volume”
Handbook of Neurosurgery Greenberg 8th Edition and Youmans Neurological Surgery Textbook 7th Edition

5. Pires, P. W., Dams Ramos, C. M., Matin, N., & Dorrance, A. M. (2013). The effects of hypertension on the cerebral circulation. American Journal of Physiology-Heart and Circulatory Physiology, 304(12)
CPP (BP – ICP)
Normal CBF needs:
Subs. Grisea = 67 – 80 ml / 100 gr / min
Subs. Alba = 18 – 25 ml / 100 gr / min

6. Autoregulation Disturbances in TBI
Kinoshita, K. (2016) ‘Traumatic brain injury: Pathophysiology for neurocritical care’, Journal of Intensive Care, 4(1), pp. 1–10. doi:
10.1186/s40560-016-0138-3.

7. Autoregulation Disturbances in TBI
Winn, H. and Youmann (2017) Youmans & Winn Neurological Surgery. 7th edn. Philadelphia: Elsevier.

8. • Fase awal (kompensasi) = Komplians = ΔV / ΔP
• Fase lanjutan (dekompensasi) = Elastans = ΔP / ΔV Terapi ICP
• Membantu kompensasi
• Dekompensasi  kompensasi or normal state

9. Treatment Goals
ICP ≤ 20
mmHg
CPP ≥ 50
mmHg

10. Increased ICP Therapy: Virginia Step-Ladder

11. Definitive treatment
• Raised ICP is treated by removing mass lesions and/or increasing the volume available for
expansion of injured tissue
• This may achieved by :
• Reducing intracranial fluid volumes :
• CSF by ventricular drainage
• Cerebral blood volume by hyperventilation or mannitol
• Brain tissue water content by mannitol
• Removing swollen and irreversibly injured brain
• Increasing cranial volume by decompression

12. CSF drainage
• Invasive monitoring using the EVD technique
 catheter is placed into one of the ventricles through a burr hole  the gold
standard of ICP monitoring
• Drainage CSF even a small amounts produces an immediate fall in ICP and rise in
CPP
• Updated BTF guidelines state that ICP monitoring is a level IIB recommendation,
and recommend treatment of ICP > 22 mmHg to reduce mortality
Nancy Carney et al. Guideline fo the Management of Severe Traumatic Brain Injury 4th
Edition. Brain Trauma Foundation. 2016.

13. CSF drainage
• CSF drainage pressure should be set at about
•  20 cmH2O

14. Hiperosmolar therapy
• Osmotherapy with mannitol has been used since the 1960s
• Mannitol  increases CBF by plasma expansion, decreasing the blood
viscosity via deformed erytrocytes, and promoting osmotic diuresis
• Hypertonic saline promotes the flux of water across the BBB and
improved blood flow by expanding the plasma volume.
Nancy Carney et al. Guideline fo the Management of Severe Traumatic Brain Injury 4th
Edition. Brain Trauma Foundation. 2016.

15. Mannitol
• Mannitol is a mannose-derived sugar
• Maximum effects are reached after 30 to 40 minutes
• Duration of action varies between 2 and 12 hours
• The recommendations of the 3rd edition of the BTF guidelines were as follows:
• If CPP remain < 60  MAP can be increased with combination of fluid resuscitation and
pressor (phenylephrine)
Nancy Carney et al. Guideline fo the Management of Severe Traumatic Brain Injury 4th
Edition. Brain Trauma Foundation. 2016.
Mannitol (0.25–1 gm/kg) is effective for the control of elevated
ICP while avoiding hypotension (Level lI)

16. Hypertonic saline solutions
• HSSs were introduced into clinical practice more than 20 years ago for the treatment of
traumatic shock
• They generate greater osmolality than mannitol
• Infusion of 7.5% solution (equimolar to 15% mannitol) gives 2560 mOsm/L
• HSS has inotropic, antiinflammatory, and immunomodulatory properties, and might
improve hepatic and splanchnic blood flow
• Concentrations range from 3.5% to 23.4%
Usual practice is to use boluses at 7.5% at 1.5 to 4 mL/kg

17. Analgesia, sedation and paralysis
• Endotracheal intubation, mechanical ventilation, trauma, surgical interventions, nursing care
and ICU procedures  potential causes of pain
• Narcotics (morphine, fentanyl and remifentanil) should be considered first line therapy 
provide analgesia, mild sedation and depression of airway reflexes (cough)
• Adequate sedation potentiates analgesics 
• Provides anxiolysis (limits elevations of ICP related to agitation,discomfort, cough or
pain)
• Decrease O2 consumption, CMRO2, and CO2 production
• Improves patient comfort
• Prevents harmful movements

18. Analgesia, sedation and paralysis
• Routine use of neuromuscular blocking agents(NMBAs) to paralyze patients with TBI
is not recommended
• NMBAs reduce elevated ICP and should be considered as second line therapy for
refractory intracranial hypertension
• Propofol  is the hypnotic of choice in patients with an acute neurologic insult,
“it is easily titratable and rapidly reversible once discontinued”

19. Barbiturate Coma
• Patient with severe TBI refractory to basic maneuvers, hyperosmolar therapy and
intraventricular catheter drainage  continous pentobarbital drip with EEG monitoring were
considered
 40 % patients survived
 68 % patients had good functional outcome
• 2016 BTF
 Do not advocate barbiturate therapy as prophylaxis
 When treating refractory intracranial hypertension with barbiturates, avoiding
hemodynamic instability is recommended
Michael A Vella, et all. Acute Management of Traumatic Brain Injury. Surg Clin North Am.
2017; 97(5): 1015-30. doi:10.1016/j.suc.2017.06.003

20. Decompressive Craniectomy
• The RESCUEicp  patient with refractory ICP > 25 mmHg for 1-12 hours
• Recommended of large frontoparietal DC
• Higher rate of vegetative state but lower mortality, severe disability and upper
severe disability
Michael A Vella, et all. Acute Management of Traumatic Brain Injury. Surg Clin North Am.
2017; 97(5): 1015-30. doi:10.1016/j.suc.2017.06.003
• Decompressive craniectomy (DC) is a surgical procedure that involves removal of a
large section of the skull
Reduces ICP by giving extra space to the swollen brain, and it may quickly
prevent brainstem herniation

21. Decompresive Craniectomy
• The goal of this thorough discussion is to determine if intervention to
preserve the patient’s life, despite a probable long-term limitation in
function, is desired.
Adequate bony decompression over the lateral temporal lobe is
paramount for maximizing the opportunity to decompress the
brainstem.

22. Decompresive Craniectomy
Level IIA–to improve mortality and overall outcomes
• 1. Secondary DC performed for late refractory ICP elevation is
recommended to improve mortality and favorable outcomes.
• 2. Secondary DC performed for early refractory ICP elevation is not
recommended to improve mortality and favorable outcomes†.
• 3. A large frontotemporoparietal DC (not less than 12 × 15 cm or 15
cm in diameter) is recommended over a small frontotem-
poroparietal DC for reduced mortality and improved neurological
outcomes in patients with severe T
Hawryluk GWJ, Rubiano AM, Totten AM, et al. Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy
recommendations. Neurosurgery. 2020;87(3):427-434.