Increased intracranial pressure

1
Increased intracranial pressure
2
Normal ICP

• 0-15 mm Hg.
• Average intracranial volume 1700 ml
• Brain (80) 1400 ml
• CSF (10) 150 ml
• Blood (10) 150 ml

3
Cerebral blood flow

• CBF
• CPP (cerebral perfusion pressure)
• ________________________________
• CVR (cerebrovascular resistance)

4
MAP 100
CPP 90 mm Hg ICP
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Figure 26-3. Cerebral pressure. CPP MAP -
ICP. For adequate CBF, CPP should exceed 50 mm
Hg.
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Cerebral dynamics

• CPP MAP - ICP
• MAP 1/3 of (systolic MINUS diastolic blood
  pressure) ADDED TO diastolic BP
• Normal cerebral perfusion pressure
• 70 - 100 mm Hg.

6
Cerebral dynamics

• Ischemia if CPP lt 30-40 mm Hg.
• need 60 - 70 mm Hg. MINIMALLY
• After head injury cerebral blood flow depends on
  SYSTOLIC BP

7
Causes of increased ICP

• 1) space occupying lesions
• 2) cerebral edema
• 3) hydrocephalus
• 4) stroke
• 5) subarachnoid hemorrhage

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Intracranial volume
9
Causes of increased ICP due to changes in Brain
Parenchyma

• Head injuries
• Space occupying lesions
• - tumor
• - abscess
• Infections
• - encephalitis
• - meningitis

10
Causes of increased ICP due to changes in Brain
Parenchyma

• Cerebral edema due to cardiac arrest
• Trauma related to intracranial surgery

11
Causes of increased ICP due to changes in
blood/vasculature

• Hematomas
• subdural
• epidural
• intracerebral
• Subarachnoid hemorrhage

12
Causes of increased ICP due to changes in
blood/vasculature

• Aneurysm
• Arteriovenous malformation (AVM)
• Thrombosis

13
Causes of increased ICP due to changes in CSF

• Hydrocephalus

14
Neurologic examination

• Mental status
• Sensation
• Cranial nerves
• Motor function
• Cerebellar function
• Reflexes

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Early signs of increased ICP

• 1) LOC restlessness, agitation, lethargy
• 2) PUPILS delayed or sluggish reaction,
  unilateral changes in size
• 3) MOTOR pronator drift, weakened hand grasp

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Early signs of increased ICP

• 4) HEADACHE in the early AM with nausea
  vomiting
• 5) SPEECH slowed or slurred
• 6) MEMORY mildly impaired

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Late signs of increased ICP

• 1) LOC difficult to arouse, decreasing Glasgow
  Coma Scale
• 2) PUPILS fixed or dilated
• 3) MOTOR posturing, flaccid muscles

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Posturing
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What posturing indicates..

• Decorticate posturing
• Damage to upper corticospinal tract
• Decerebrate posturing
• Brain stem damage

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Late signs of increased ICP

• 4) HEADACHE increasing with projectile vomiting
• 5) SPEECH decreasing, or with groans or moaning
• 6) VITAL SIGNS CUSHINGS TRIAD

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Cushings Triad

• reflects rising ICP with direct pressure on the
  medullary center of brain
• often seen in the terminal stage
• associated with irreversible brain stem damage

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Cushings Triad

• INCREASED BP WITH WIDENING PULSE PRESSURE
• BRADYCARDIA
• RESPIRATORY IRREGULARITIES

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Changes in Vital signs with Increased ICP
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Herniation
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Herniation
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Remember!!!!!!!

• LOC IS THE BEST AND EARLIEST INDICATOR OF
  INCREASED INTRACRANIAL PRESSURE

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Treatment of increased ICP

• When ICP gt 20 - 25

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Treatment - Respiratory support

• hyperventilation
• increase RR TV to decrease pCO2 to 30 -35
• causes vasoconstriction of cerebral arteries
• reduces CBF increases venous return

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Treatment - Respiratory support

• adequate oxygenation
• keep pO2 gt 60
• treat ICP spikes with hyperventilation with AMBU
  bag

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Nursing Measures

• suction prn NO MORE THAN 15 SECONDS!
• time limit prevents increase in CO2 which is a
  potent cerebral vasodilator that can increase ICP
• hyperventilate with 100 for 1 minute prior to
  suctioning (if no COPD) synchronize bagging with
  pt.

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Nursing Measures

• check ventilator settings
• trach care q 4 h
• monitor ABG's pulse oximetry
• oxygen as ordered
• if ICP increases during suctioning lidocaine
  ETT/trach first!
• ??muscle relaxant for respiratory synchrony

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Treatment - Drug therapy

• Osmotic diuretics/hyperosmolar therapy
• Mannitol 1 gr/Kg. continuous infusion

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Osmotic diuretics/hyperosmolar therapy

• administered through a filter
• keep serum osmolality 310 -315 mosm/L

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Osmotic diuretics/hyperosmolar therapy

• check serum osmolality
• glucose
• electrolytes (esp. K)
• accurate IO
• foley

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Treatment - Drug therapy

• Corticosteroids
• dexamethasone (Decadron)
• or
• methylprednisolone (Solu-Medrol)

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Treatment - Drug therapy

• must be tapered otherwise adrenal insufficiency
  could develop
• SE gastric irritation, stress ulcer, GI bleed
• To prevent
• H2 blockers
• antacids

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Treatment - Drug therapy

• Seizure prophylaxis
• Phenytoin (Dilantin)
• Carbamezepine (Tegretol)

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Treatment - BP control

• Goal keep systolic BP gt 90 mm Hg
• CPP gt 70 mg. Hg.
• Treatment
• hypertension when SBP gt 150 -160 or
• CPP gt 85 -100 mm Hg
• in adult who was previously normotensive

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Hypertension control

• IV Beta -blockers
• OR
• labetalol (Normodyne Trandate) alpha beta
  blocker
• Diuretics

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Other drugs

• muscle relaxants, muscle paralysis, sedation
• pancuronium bromide (Pavulon)
• benzodiazepines
• barbiturates
• MSO4 in small doses 1mg/hr

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Hypotension control control

• Phenylephrine hydrochloride (Neo-Synephrine)
• vasopressor
• alpha adrenergic agonist
• powerful peripheral vasoconstrictor with little
  effect on heart

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Treatment - Temperature control

• control hyperthermia
• antipyretic drugs (Tylenol)
• hypothermia blanket

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Temperature

• assess Q 2 hours initiate treatment for
  increase
• guard against shivering Tx chlorpromazine
  (Thorazine)
• if on cooling blanket remove when body temp 1-2 F
  above normal (99.8)

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Treatment - Seizure control

• Phenytoin (Dilantin) 100 mg TID or QID
  PO/IV/tube
• Carbamezepine (Tegretol)
• Phenobarbital

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Treatment - Fluid restriction

• range 900 -2500 ml/24 hours
• accurate IO IV, PO, enteral
• notice over bed
• divide into three 8 hour shifts

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Nursing Measures

• monitor Specific Gravity
• (DI S.G. 1.001-1.005 output gt 200 cc or more
  for 2 consecutive hours)
• administer stool softeners avoid enemas or
  straining

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Treatment - CSF drainage

• ventricular drainage (into lateral ventricle for
  drainage of CSF) TEMPORARY!!!
• inserted through Burr hole in skull
• ventriculostomy is commonly used for
  hydrocephalus R/T SAH

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Nursing measures

• closed system meticulous care to decrease
  infection risk
• collection bag usually level with auditory meatus
• note rate amount color of drainage

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Ventricular drainage

• HOB elevation determined by MD know correct
  level!
• strict asepsis
• dressing change q 48 h (prn)
• closed system
• monitor CS wbc count

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ICP Monitoring
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ICP monitoring
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ICP monitoring
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ICP monitoring
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Continuous ICP monitoring

• be familiar with equipment
• read interpret waveforms
• know what to do for atypical readings
• maintain strict asepsis
• monitor CS wbc count

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ICP monitoring
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Treatment - Surgery

• remove or debulk lesion
• hematoma
• abscess
• tumor
• remove or debulk infarcted and necrotic tissue

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Treatment - Barbiturate coma

• when ICP does NOT respond to conventional therapy
• underlying therapeutic principle
• decreased cerebral metabolism decreased CBF
  decreased ICP

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Barbiturate coma

• pentobarbital (Nembutal)
• sometimes
• thiopental sodium (Pentothal)

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Barbiturate coma

• loading dose IV
• 3-10 mg/Kg over 15 -30 minutes
• then
• 1 -2 mg/Kg/hr
• keep serum level 3 -4 mg/dL

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Barbiturate coma

• once coma induced - lose usual parameters of
  neuro assessment (e.g., pupils, gag, swallowing)
• need complete monitoring
• ICP Swan A line EKG, central peripheral
  IV, ventilator, ETT/trach,
• foley

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Barbiturate coma

• should have almost immediate effect of decreased
  ICP
• after pt. has had ICP lt 20 mm Hg (or whatever
  protocol level) for 24 -72 hours drug tapered

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Barbiturate coma

• pentobarbital stored in body fat
• brain death criteria cannot be established until
  drug cleared from body impact on organ
  donation

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Nursing Managementpositioning turning

• HOB 30-45 in neutral position facilitates
  venous return from head
• AVOID prone
• Trendelenberg
• extreme neck flexion
• hip flexion gt 90

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Positioning turning

• use neck rolls or collar
• log roll turn Q2h skin care
• if awake, tell pt. to exhale during turning, or
  moving (no Valsalva)
• assist pt. in moving up in bed
• patient not to push with heels or arms or against
  footboard
• passive ROM

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Nursing Management

• Major objective
• identify protect patient from sudden increase
  in ICP decreased CPP

69
Neurological assessment

• assess baseline reassess
• compare to previous findings
• LOC
• pupil size reaction to light
• eye movement
• motor/ sensory function

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Neurologic examination

• Mental status LOC
• appearance affect, grooming, emotional status,
  posture
• cognition LOC, memory, attentions span,
  judgement
• emotional stability moods, feeling, thought
  process
• speech language voice quality, articulation,
  content, comprehension

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Cranial nerves ocular movements
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Glasgow Coma Scale
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Vital signs

• assess compare with previous
• REMEMBER - VS compare poorly with early
  neurological deterioration

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General nursing interventions

• maintain seizure precautions
• apply elastic stockings consecutive sequential
  air boots monitor for DVT
• administer basic hygiene preventive
  interventions to control consequences of
  immobility
• No noxious stimuli! CALM environment

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General nursing interventions

• no noxious stimuli! CALM environment
• patient can hear!
• use therapeutic touch
• know medications!
• action, dosage, preparation, route, SE,
  contraindications interactions

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Head injury
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Incidence

• 1 every 16 seconds
• mortality almost 50
• highest group 15 - 24 years
• MVAs
• males gt females 31

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Mechanisms of injury
81
Types of brain injuries
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Main problems

• CEREBRAL EDEMA
• INCREASED ICP
• from cerebral edema expanding lesions
  (hematoma)

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Mechanisms of injury

• Acceleration
• when immobile head is struck by a moving object
• Deceleration
• head is moving hits an immobile object

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Mechanisms of injury

• Acceleration - deceleration
• moving object hits the immobile head then the
  head hits an immobile object
• Deformation
• results in disruption of integrity of skull

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Other categorizations of head injury

• Blunt
• Penetrating
• Coup/contrecoup

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Risk factors

• Alcohol
• No seat belt
• No helmet

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Types of head injuries

• Scalp
• Skull
• Brain

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Scalp injuries

• abrasion
• scraping away
• contusion
• bruise
• laceration
• wound or tear, may bleed profusely

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Scalp injuries

• TREATMENT
• skull films
• abrasion none
• ice
• suturing

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Skull fractures

• Types
• Linear
• Comminuted
• Depressed
• Basal

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Linear fractures

• simple fracture
• crack in skull
• 70-80 of skull fractures
• treatment
• bedrest
• neuro check

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Comminuted fracture

• fragmentation of bone into many pieces or
  multiple fracture lines

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Depressed skull fracture

• inward depression of the bone fragments to at
  least the thickness of the skull
• hair, dust, debris may be found
• dura may or may not be torn

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Depressed skull fracture

• Treatment surgery debride
• craniectomy (depressed or comminuted)
• cranioplasty
• insertion of bone or artificial graft
• may be done immediately or postponed for 3-6
  months (if cerebral edema present)
• DEXAMETHASONE (decadron)

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Basal skull fracture Base of skull

• may be linear, comminuted, or depressed
• can be more serious
• CSF can leak through nose/ear
  rhinorrhea/otorrhea

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Basal skull fracture

• increased risk of meningitis
• appearance of blood encircled by yellowish stain
  on dressing or bed linen
• "halo 'sign blood encircled by CSF

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Basal Skull Fracture Anterior fossa fracture

• fracture of the Paranasal sinus
• rhinorrhea
• subconjunctival hemorrhage
• periorbital ecchymosis (raccoon's eyes)

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Basal skull fracture Anterior Fossa Fracture
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Basal skull fracture Middle fossa fracture

• associated with fracture of temporal petrous
  bone involves the middle ear
• otorrhea
• hemotympanum
• conductive hearing loss

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Middle fossa fracture

• may have signs of vestibular dysfunction
  vertigo, nausea, nystagmus
• facial nerve palsy (bell's palsy) -- appears 5-7
  days after injury
• ecchymosis over mastoid bone "Battle's" sign --
  does not develop for 24-36 hours

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Basal Skull FractureMiddle Fossa fracture
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With skull fractures if dura torn

• ? prophylactic antibiotics
• most leaks resolve spontaneously within 7-10 days
  
• to aid resolution of leak LPs BID to remove 30cc
  CSF

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If Dura torn

• lumbar catheter for continual drainage
• craniotomy to repair tear surgically

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Brain injuries
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Focal brain injuries

• cerebral contusion
• bruising of the surface of the brain
  hemorrhagic area present
• cerebral laceration
• actual tearing of cortical surface of brain
• (may be found with contusion)

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Focal brain injuries

• Can cause cerebral edema with increased ICP
• SS R/T anatomic area involved
• CT scan to identify contusions
• Treatment increased ICP

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Focal brain injuries

• possible rehabilitation
• management of postinjury problems seizures

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Types of diffuse brain injuries

• concussion
• diffuse axonal injury

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Concussion

• means to shake violently
• S S
• immediate unconsciousness (seconds, minutes,
  hours)
• momentary loss of reflexes
• momentary (few seconds) respiratory arrest

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Concussion

• possible amnesia
• headache, drowsiness, confusion, dizziness,
  irritability, giddiness, visual disturbances
  (seeing stars), gait disturbances

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Diffuse axonal injury

• widespread damage to axons in the white matter in
  the hemispheres
• R/T
• high speed acceleration - deceleration associated
  with MVA's

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Diffuse axonal injury

• SS
• immediate coma
• decerebration an initially low ICP
• 94 die or remain in chronic vegetative state
  long term care

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Hematomas
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Epidural hematoma

• also called extradural hematoma
• bleeding into the potential space between the
  skull dura mater
• 2 of all types of head injury
• 85 also have a skull fracture

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Epidural hematoma
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Epidural hematoma

• DX CT scan
• seen most often in children young people
  because the dura is less firmly attached to bone

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Epidural hematoma

• SS
• momentary unconsciousness followed by a lucid
  period (few hours to 1-2 days) longer if venous
  bleed involved
• then
• decreased LOC
• other SS HA, seizures

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Epidural hematoma

• Treatment surgery
• Burr holes to evacuate clot ligate bleeding
  vessels

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Burr holes
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Jackson - Pratt drain in Burr hole
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Subdural hematoma

• bleeding between dura mater arachnoid layer of
  the meninges
• causes direct pressure on the brain
• 10 -15 of head injuries develop subdural
• hematomas

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Subdural hematoma
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Subdural hematoma
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Subdural hematoma

• Diagnosis CT scan
• S S
• 3 categories based on interval between injury
  appearance of ss

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Categories of subdural hematoma

• A) ACUTE within 48 hrs
• B) SUBACUTE 2 days - 2 weeks
• C) CHRONIC 2 weeks to several months

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Subdural hematoma

• associated with cerebral contusion laceration
• headache, drowsiness, slow cerebration, confusion
  -- all worsen
• ipsilateral pupil dilates fixed
• hemiparesis late sign

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Subdural hematoma

• elderly pts. chronic alcoholics prone to
  subdurals -- r/t cerebral atrophy
• treatment
• small ones medical tx
• large surgery burr holes

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Intracerebral hematoma

• bleed into cortical substance
• 2 -3 of head injuries
• R/T contusions -- tend to occur in frontal
  temporal lobes

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Intracerebral hematoma

• Diagnosis CT scan
• SS
• unconsciousness, decreased LOC, HA, hemiplegia on
  contralateral side, dilated pupil on side of clot
• Treatment mortality high
• injury to blood vessels can cause vasospasm

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General head injury treatment

• treat all head injured patients for possible
  cervical fracture
• immediately immobilize neck
• patent airway but do not hyperextend
• jaw thrust maneuver

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General head injury treatment

• AIRWAY
• all unconscious head injured patients ETT to
  prevent aspiration
• NO CERVICAL HYPEREXTENSION
• clear nose mouth of blood, mucus, drainage

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General head injury treatment

• aspiration prior to admission possible even with
  negative CXR
• limit suction lt 15 seconds
• do not use nasal passage for suction until basal
  skull fracture dural tear ruled out
• oxygen/ventilator

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General head injury treatment

• vital signs
• assess pulses capillary refill
• peripheral IV

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General head injury treatment

• EKG monitoring
• if BP low --? occult bleeding in abdomen
• if BP high --R/T head injury -- ICP protocol

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General head injury treatment

• Labs
• CBC, electrolytes, TC, ABG's, drug screen
• Xray
• cervical spine, chest, long bones, pelvis

137
General head injury treatment

• CT
• immediate if patient unconscious focal signs
  are present
• head to toe exam for other injuries
• Glasgow Coma scoring

138
Detailed neuro exam

• LOC
• pupillary signs responses
• eye movement
• oculovestibular oculocephalic corneal
  reflexes gag brain stem fx
• motor responses

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Head injury

• peak swelling 72 hours after injury

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Other measures

• NG (if no basal skull fx)
• keep gastric pH _at_ 4-5

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Nutrition support

• jejunal feedings by day 7
• patient in hypercatabolic state
• as early as 24 - 48 hrs. after injury
• 140 of caloric requirements if not paralyzed
• 100 if paralyzed
• 15 protein

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Interdisciplinary rehabilitation

• rehabilitation team approach maintenance,
  prevention, restoration
• Rancho Los Amigos Scale
• PT for paresis/paralysis

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Interdisciplinary rehabilitation

• OT for ADL performance evaluation deficits
• Speech therapy for communication feeding
  swallowing
• Neuro-opthamologist for visual deficits
• Neuropsychologist for cognitive deficits

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Interdisciplinary rehabilitation

• Urologist for bowel/bladder problems
• Psychiatrist for behavioral problems
• National Head Injury Foundation

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Intracranial hemorrhage

• Bleeding into the brain tissue or subarachnoid
  space
• usually due to
• head injury
• aneurysms

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Aneurysm

• Localized arterial wall dilation that develops
  secondary to a weakness of the arterial wall
• 90 congenital
• 80 occur in Circle of Willis

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Cerebral arteries
149
Circle of Willis
150
Circle of Willis
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Incidence of SAH

• 18, 000 in U.S. annually
• 20 - 40 die at initial bleed
• 1/3 of survivors have residual changes
• females gt males
• peaks in 50s

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Risk factors

• Hypertension
• Cocaine use
• Head trauma
• Congenital

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SAH

• Specific signs symptoms depends on
• location of hemorrhage
• degree of increased ICP

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Pathophysiology

• bleeding commonly stopped by formation of
  fibrin-platelet plug at point of rupture by
  tissue compression
• within three weeks hemorrhage undergoes
  re-absorption

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Pathophysiology

• serious risk of recurrent rupture 7 - 10 days
  after original hemorrhage
• massive hemorrhage (30 - 50 ml)
• produces rapid filling of ventricular system OR
• produces a hematoma that distorts subarachnoid
  space brain tissue

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Classification

• Saccular (Berry)
• Fusiform

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Types of aneurysms
158
Complications

• Rebleeding
• Vasospasm
• Hydrocephalus

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Complication - Rebleeding

• greatest cause of mortality
• peak 24 hours and in 7 - 10 days
• treatment clipping
• if no surgery Antifibrinolytic agents
  (Aminocaproic Acid Amicar) to prevent clot
  dissolution
• SE vasospasm

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Complication - Vasospasm

• narrowing of vessel lumen
• usually in vessel adjacent to ruptured aneurysm
• may spread throughout all major vessels _at_ base of
  brain
• produces symptoms of ischemia
• 30 - 50 after SAH
• 65 after surgery

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Vasospasm treatment

• DRUG
• Nimodipine (nimotop)
• cerebroselective Calcium channel blocker
• 60 mg. Q 4 hour no later than 48 hours after
  hemorrhage
• continue for 21 days
• monitor BP carefully

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Vasospasm treatment

• DRUG
• Nicardipine (Cardene)
• alternative to Nimodipine

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Vasospasm treatment

• Intravascular volume expansion
• Induced arterial hypertension
• Hypervolemic - hypertensive therapy

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Vasospasm treatment

• Hypervolemic - hypertensive therapy
• increases volume pressure
• forces blood through spastic vessels
• increases flow to ischemic areas

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Vasospasm treatment

• Hypervolemic - hypertensive therapy
• keep low Hct (40) low viscosity
• albumin
• IV fluids
• keep CVP 10 mm Hg. (PCWP 18 - 20 Hg.)

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Vasospasm treatment

• Hypervolemic - hypertensive therapy
• keep SBP 150 or higher
• clipped 200
• unclipped 160
• drugs
• Dopamine, Dobutamine, Levarterenol, Metaramine

167
Complication - Hydrocephalus

• caused by blood in subarachnoid space
• prevents adequate CSF circulation
• contributes to increased ICP
• teatment shunt
• ventriculoperitoneal
• ventriculoatrial

168
Aneurysm clinical manifestations

• most are asymptomatic until the time of bleeding
• some are uncovered _at_ autopsy and NEVER bleed
• warning signs in 49

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Clinical manifestations

• Headache
• This is the worst headache of my life
• Localized S S depend on size location of
  aneurysm

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Clinical manifestations

• Dysfunction of
• CN II optic vision
• CN III occulomotor eye movements, pupils
  size, accomodation
• CN V trigeminal eye movement, sensations of
  head face

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Cranial nerves ocular movements
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Clinical manifestations

• Hemiparesis/hemiplegia
• Vomiting
• Seizures
• Meningeal irritation
• stiff neck
• leg back pain

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Diagnostic studies

• Lumbar puncture
• done with caution due to increased opening
  pressures (nl 50 - 180 mm H2O)
• bloody CSF with Xanthochromia (hemolyzed RBCs)
• CT scan or MRI
• blood in subarachoid space, clots
• displaced structures

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Diagnostic studies

• Cerebral arteriogram
• identifies aneurysm structure location
• identifies vessels supplying aneurysm
• identifies local or general vasospasm
• outlines cerebral vascualture
• small lt 15 mm
• large 15 -25 mm
• giant 25 - 50 mm
• super giant gt 50 mm

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Cerebral arteriogram
177
Treatment

• Surgery
• Corticosteroids
• Anticonvulsants
• Phenytoin (Dilantin)
• Phenobarbital
• Antihypertensives

178
Treatment

• Antifibrinolytics/hemostatic agents
• Aminocaproic Acid (amicar) 24 -36 g IV Q day for
  3 weeks
• Analgesics/antipyretics
• Tylenol
• Tylenol with codeine
• Pituitary hormone
• Vasopressin (pitressin)

179
Treatment

• Stool softener
• Electromechanical
• ventilatory support
• hypothermia blanket
• EKG monitoring
• arterial BP monitoring

180
Supportive treatment

• Elevate HOB
• Subarachnoid precautions
• dim lights
• private room
• decease noise
• limit visitors
• NO Valsalva

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Supportive treatment

• Seizure precautions
• Foley
• No restraints

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Interventional radiology

• Balloon occlusion of aneurysm
• Balloon occlusion of parent vessel
• Percutaneous transfemoral approach

183
Surgery

• Craniotomy
• Microsurgery
• Controlled systemic hypotension during the 5 - 10
  minutes of the dissection of the aneurysm
• bloodless field
• collapsed aneurysm

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Surgery

• Berry (saccular ) clip
• Fusiform wrap with special gauze acrylic wrap

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Aneurysm surgery
186
Aneurysm clipping
187
Arteriovenous malformation

• Congenital
• Tangles of thin walled blood vessels without
  intervening capillaries
• Some large others microscopic

188
AVM treatment

• Neuroradiologic procedures
• embolization
• laser
• Surgery

189
Neurosurgery
190
Cranioplasty

• replacement of part of cranium with a plate
• metal (tantalum)
• nonmetallic material (methyl methacrylate)
• closure can be delayed for 6 months to 1 year

191
Surgical approaches

• SUPRATENTORIAL
• INFRATENTORIAL

192
Supratentorial

• above double fold of dura called tentorium
• incision within hairline over involved area

193
Surgical approaches

• Supratentorial
• cerebrum (cerebral hemispheres)
• approach used to get at
• frontal lobe
• parietal lobe
• temporal lobe
• occipital lobe

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Supratentorial
195
Infratentorial

• below tentorium
• suboccipital incision made with patient in
  sitting position

196
Surgical approaches

• Infratentorial
• brain stem
• midbrain
• pons
• medulla
• cerebellum

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Infratentorial
198
Cranial surgery

• Microsurgery

199
Stereotaxis

• precisely localizing areas in brain
• stereotactic probe or electrode passed to target
  area
• placement confirmed by CT scan

200
Stereotaxis

• done under local anesthesia
• used to
• remove or biopsy deep, small subcortial tumors
  that previously were inaccessible by routine
  surgery

201
Uses for Stereotaxis

• ablate lesions in extrapyramidal disorders
  causing rigidity uncontrolled movements
• aspirate cysts, abscesses, hematomas
• implant radioactive seeds
• interrupt pain fibers/centers

202
Laser

• narrow laser beam
• excellent for removing highly vascular lesions
  due to ability to simultaneously dissect,
  coagulate, vaporize abnormal tissue
• no bleeding into the field

203
Laser

• no trauma to surrounding tissue
• allows removal of tumors proximal to delicate
  cerebral

204
Cryosurgery

• liquid nitrogen to produce temperatures as low as
  -20 c
• destroy abnormal tissue by using cold
  temperatures

205
Stereotactic radiosurgery

• can be performed with gamma knife, which is
  actually not knife but a helmet containing
  radioactive cobalt
• focus so precise on malignant tissue one
  treatment enough

206
Stereotactic radiosurgery

• surrounding tissue not harmed
• only a few facilities have this because of its
  expense
• may take from 1 to 3 years lag time before lesion
  is totally destroyed

207
Measures to preserve cerebral function during
surgery

• HYPOTENSION
• to control cerebral blood flow during repair of
  aneurysm or AVM
• accomplished by
• use of sitting position
• vasodilators (sodium nitroprusside nipride)
• effects of anesthetics (halothane)

208
Measures to preserve cerebral function during
surgery

• HYPOTHERMIA
• reduces oxygen consumption of brain thus
  decreasing chance of neuronal damage
• metabolic by-products also reduced
• accomplished by hypothermia blanket

209
Measures to preserve cerebral function during
surgery

• HYPERVENTILATION
• to decrease ICP by decreasing CO2
• slows cerebral blood flow
• constricts cerebral vessels so increases venous
  return
• reduces intracranial volume
• accomplished by ETT ventilator

210
Complications during surgery

• 1)elevated ICP controlled by
• hyperventilation
• osmotic diuretics
• dexamethasone (Decadron)
• 2) seizure activity controlled by
• phenytoin (Dilantin) (pre post op)

211
Complications during surgery

• 3) infection controlled by
• aseptic techniques
• antibiotics
• 4) venous air embolism
• potential problem when surgery in sitting
  position
• having head higher than heart causes negative
  pressure in cerebral veins venous sinuses

212
Complications during surgery

• 4) venous air embolism
• air in venous system goes to right heart
• patient monitored with doppler sensor to detect
  air
• if air detected, surgeon identifies occludes
  entry site
• anesthesiologist aspirates air through the
  central venous catheter

213
Complications during surgery

• 4) venous air embolism
• patient vital signs are stabilized surgery
  continues
• if entry site of air cannot be identified,
  surgery terminated patient placed in supine
  position immediately monitored for transient
  neurologic deficits
• air embolus can be fatal

214
Surgical approaches

• By Fossa
• Anterior fossa
• frontal lobe
• Middle fossa
• temporal lobe
• parietal lobe
• occipital lobe
• Posterior fossa
• brain stem cerebellum

215
Surgical approaches

• Supratentorial
• Infratentorial

216
Preoperative care

• antiseptic shampoos to head
• no coughing, no enemas, no leg exercises due to
  increased ICP
• teach relaxation techniques
• discuss tubes, monitors, appliances
  (ventilator)

217
Preoperative care

• hair not usually removed unless absolutely
  necessary - show how to cover with stockinet
  caps, scarves, hats, or a hairpiece
• preop med based on specific pathology LOC
• NPO

218
Preoperative care

• preop corticosteroids (dexamethasone) to control
  cerebral edema
• anesthesia light since the brain itself has no
  pain receptors
• osmotic diuretic (mannitol) may be given to aid
  in decreasing increased ICP

219
Preoperative care

• antibiotics prescribed if organism isolated or as
  prophylaxis, esp. if ventriculostomy is
  anticipated
• drains (Jackson - Pratt for 24 - 48 hours)
• could be entry site for infection

220
Preoperative care

• anticonvulsant
• careful neuro cognitive assessment performed
  and documented to use as reference during surgery
  immediately postop

221
Postoperative care

• depends on specific problem
• must have following data
• neurologic status specific deficits
  preoperatively
• other medial problems existing preoperatively
• purpose of surgery

222
Postoperative care

• Needed data
• actual procedure used
• location of the area of involvement whether a
  bone flap was replaced if a large area was
  evacuated
• intraoperative problems

223
Postoperative nursing goals

• 1) prevention recognition of complications
• 2) evaluation of patient's neurologic status
• 3) prevention, recognition, control of
  increased ICP
• 4) supportive care
• 5) rehabilitation

224
Postoperative nursing care

• usually ICU
• hemodynamic monitoring
• many IV lines but keep fluid amount low to
  prevent cerebral edema
• bed have alternating pressure mattress
• hypothermia blanket to rewarm patient

225
Postoperative nursing care

• IV meds immediately available for tx of
• vasospasm
• increased ICP
• HTN
• hypotension
• infection
• seizures
• cardiac arrhythmias

226
Postoperative nursing care

• seizure precautions
• antiembolic stockings a sequential compression
  device
• ETT/ventilator/suction/oxygen

227
Postoperative nursing assessment

• document LOC (glasgow coma scale)
• pupillary signs
• ocular movement
• sensory function
• motor function
• vital signs
• compare baseline data to preoperative
  intraoperative data

228
Postoperative nursing assessment

• neuro assessments q 15-30 minutes until stable
  (or more frequently if unstable) no time frame
  can be placed on this process, can vary from 4
  hours to days
• once patient is stable, assessments are q 1 hour
  initially then every 2-4 hours

229
Postoperative nursing assessment

• urine specimens to measure osmolality specific
  gravity
• blood for electrolytes, therapeutic drug levels,
  ABGs
• cultures from sputum, urine, blood, wound
  sources if fever

230
Proper positioning

• Supratentorial approach
• HOB elevated to 30
• turn patient to either side unless a large area
  of tissue removed
• if removed, patient should not lie on operated
  side

231
Proper positioning

• Infratentorial approach
• relatively flat with a very small pillow to neck
• flat position prevents pressure on brain stem
• can turn to either side but may not be allowed by
  some surgeons to lie on back

232
Proper positioning

• Infratentorial approach
• can experience dizziness so remind patient no
  sudden moves (dizziness due to edema of CN VIII)
• maintain position for 1 week with very gradual
  elevation to 30 if tolerated

233
Postoperative nursing assessment

• oral fluids
• (after 24 hours) post nausea
• if patient able to swallow (CN IX X gag
  swallow)
• watch for CSF leak

234
Postoperative nursing assessment

• inspect eyes q 2 hours for drying or abrasions
  blink corneal may be absent
• periorbital swelling (48 - 72 hours eye may be
  swollen shut)