This document discusses raised intracranial pressure (ICP) and Glasgow Coma Scale (GCS). It defines autoregulation of cerebral blood flow and how ICP, mean arterial pressure, and cerebral perfusion pressure interact. Causes of raised ICP include increased brain volume from tumors or hemorrhage, increased CSF volume, and increased blood volume. Signs and symptoms of raised ICP and methods for monitoring and managing high ICP both medically and surgically are described. The GCS is introduced as a scale for measuring level of consciousness.

1. Raised ICP & GCS
Momen Ali Khan
Neurosurgery Resident
Department Of Neurosurgery
Dhaka Medical College Hospital

2. Autoregulation of CBF

3. Autoregulation
Autoregulation is defined as the intrinsic ability of an organ to maintain a
constant blood flow despite changes in perfusion pressure.

4. Autoregulation of CBF
Maintaining an almost constant cerebral blood flow (CBF) across a
range of MAP between 50 and 150 mmHg (or higher in the setting of
chronic hypertension) is known as cerebral autoregulation.

5. Intracranial Pressure And Cerebral Blood Flow
The brain depends on continuous perfusion for oxygen and glucose
delivery, and hence survival.
Normal cerebral blood flow (CBF) is about 55 mL/min for every 100 g of
brain tissue.
Flow depends on cerebral perfusion pressure (CPP), which is the
difference between the mean arterial pressure (MAP) and the intracranial
pressure (ICP).

6. CPP (75–105 mmHg) = MAP (90–110 mmHg) – ICP (5–15 mmHg)
Cerebral perfusion pressure (CPP)
Mean arterial pressure (MAP)
Intracranial pressure (ICP).

7. The Monro–Kellie doctrine
Alexander Monro observed in 1783 that the cranium is a ‘rigid box’
containing a ‘nearly incompressible brain’. Any expansion in the
contents, especially haematoma and brain swelling, may be initially
accommodated by exclusion of fluid components, venous blood and
cerebrospinal fluid (CSF).

9. Uncontrolled increases in ICP result in cerebral herniation. Typically, herniation of
the uncus of the temporal lobe over the tentorium results in pupil abnormalities,
usually occurring first on the side of any expanding haematoma.
Cerebellar tonsillar herniation through the foramen magnum compresses medullary
vasomotor and respiratory centres, classically producing Cushing’s triad:
Hypertension
Bradycardia
Irregular respiration.
The patient is then said to be ‘coning’, and brainstem death will result without
immediate intervention.

10. Intracranial Pressure

11. Intracranial Pressure
The pressure that is exerted by the brain tissue, cerebrospinal fluid
(CSF) and blood.
Normal ICP
Adults 10-15 mm Hg
Children 3-7 mmHg
Infants 1.5-6 mmHg

12. Raised Intracranial Pressure (ICP)
or
Intracranial Hypertension (IC-HTN)

13. Signs & Symptoms Of Raised Intracranial Pressure
Symptoms:
1. Headache
2. Vomiting, Nausea
3. Blurred vision
4. Double vision
Signs:
1. Papilloedema
2. Bradycardia
3. Hypertension
4. Irregular respiration
5. Cranial nerve palsy (sixth cranial nerve commonly)

14. In infants features of raised ICP
1. Fontanelle is tense and bulging
2. Increase in head circumference
3. Bulging scalp veins
4. Impairment of conscious level
5. Parinaud’s syndrome results from dorsal midbrain compression,
with a loss of upgaze known as sunsetting.

15. Parinaud’s syndrome with sunsetting

16. Brain herniation. (1) Subfalcine herniation – the cingulate gyrus is herniating under the falx cerebri. (2)
Midline shift is evident. Intracranial pressure (mmHg) (3) Uncal herniation – the temporal lobe is
herniating over the tentorium cerebelli, where it can compress the third nerve. (4) Central herniation and
(5) tonsillar herniation result in brainstem compromise, manifesting as Cushing’s triad.

17. Causes of raised ICP
1. Increased brain volume
2. Increase in CSF volume
3. Increased blood volume

18. Increased brain volume
1. Intracranial space occupying lesions:
a.Brain tumors
b.Brain abscess
c.Intracranial hematoma
2. Intracranial vascular malformation
3. Encephalitis (viral, inflammatory), Meningitis
4. Hypoxic ischemic encephalopathy
5. Traumatic brain injury
6. Stroke

19. Increase in CSF volume
1. Hydrocephalous
2. Choroids plexus papilloma

20. Increased blood volume
1. Vascular malformations
2. Cerebral venous thrombosis
3. Meningitis, Encephalitis

21. Monitoring ICP
Non-Invasive:
1. Fundoscopy for papilloedema
2. Computer Tomography of Brain
3. Magnetic Resonance Imaging (MRI) of Brain
4. Transcranial Doppler Ultrasonography (TCD)
Invasive
1. External Ventricular Drainage(EVD)–Gold Standard
2. Microtransducer ICP Monitoring Devices

22. Raised ICP requires urgent evaluation and management delay risks
progression to cerebral herniation resulting in cardiovascular
instability, neurological deficit and death. Vision may also deteriorate
rapidly and irreversibly.

23. CT features of Raised ICP
It follows from the Monro-Kellie doctrine that as the CSF pressure inside the skull
increases, the brain and blood volume have to accommodate this, resulting in the
phenomenon of mass-effect, explaining the findings of raised intracranial pressure
on cross-sectional brain imaging:
1. Effacement of the ventricles, basal cisterns and other CSF spaces
2. Brain herniation
3. Loss of grey-white matter differentiation

28. Management of raised ICP
Medical
1. Head elevation
2. IV mannitol, hypertonic saline
3. Transient hyperventilation
4. Anticonvulsants: Barbiturate/ Levetiracetam
5. ICP remains refractory: Sedation, Endotracheal intubation, Mechanical
ventilation and neuromuscular paralysis.
Surgical
1. CSF drainage
2. Decompression of a surgical lesion.

30. What is Glasgow Coma Scale?
GCS t is a scale to measure level of consciousness.
In 1974, Teasdale and Jennet in Glasgow, developed a system for
measuring conscious level.

31. Components
EVM
1. Eye opening
2. Best verbal response
3. Best motor response

32. Eye opening Spontaneously
To verbal command
To painful stimulus
Do not open
4
3
2
1
Verbal Normal oriented conversation
Confused
Inappropriate/words only
Sounds only
No sounds
Intubated patient
5
4
3
2
1
T
Motor Obeys commands
Localises to pain
Withdrawal/flexion
Abnormal flexion
Extension
No motor response
6
5
4
3
2
1

33. What is the interpretation of E2V2M2?
GCS score 6 which indicate severe head injury
1. Eye opening= To painful stimulus
2. Best verbal response= Sounds only
3. Best motor response =Extension

34. Traumatic brain injury classification according to GCS
Minor head injury GCS 15 with no loss of consciousness (LOC)
Mild head injury GCS 14 or 15 with LOC
Moderate head injury GCS 9–13
Severe head injury GCS 3–8

35. Clinical scenario
A 20-year-old male struck by a cricket ball in his head with a history of brief loss of consciousness
(LOC) and admitted into your department through emergency. After 04 hours of admission his
GCS is 13/15, pulse: 60/min, BP: 150/90, Respiratory rate: 14/min.
What will be the probable diagnosis?
How will you investigate this patient?
How will you manage this patient?

36. What will be the probable diagnosis?
Moderate Head injury
How will you investigate this patient?
Urgent CT scan of Brain with Bony window view.
How will you manage this patient?
According to ATLS protocol
Following for Head injury-
1. Oxygen inhalation
2. Head end Raised
3. Nil by Mouth
4. Inf. Normal Saline
5. IV Antibiotic, Analgesic, PPI, Anticonvulsant
6. Urinary Catheterization