Increased Intracranial Pressure

1
Increased Intracranial Pressure

• Mary Ann Reilly
• BSN, MS, CRRN
• Santa Clara Valley Medical Center, Rehab Nurse
  Manager

2

• In 2004 the SJ Mercury wrote "As he was giving
  his speech he stumbled slightly and then he
  started to perspire a bit. I thought almost
  immediately that something is not right.
• His repeated vomiting prompted paramedics to
  treat him with oxygen and monitor his heart for
  half an hour -- routine care for a sudden
  food-borne illness

3
(No Transcript)
4

• The initial suspicion that Mayor Ron Gonzales had
  food poisoning Wednesday night shows just how
  difficult some strokes are to detect -- and
  experts say it offers a warning to people who
  might find themselves with similar symptoms.

5

• Gonzales' type of stroke is called an
  intraventricular hemorrhage.
• This means that a blood vessel had broken and was
  leaking into the ventricle, which carries spinal
  fluid.

6
So whats the big deal?

• Skull

7

• Components of Cranial Vault
• Meninges
• Dura
• Arachnoid
• Pia
• Brain
• Brain tissue 80-88
• Blood
• Blood 2-11
• CSF
• CSF 9-10

8
(No Transcript)
9
http//learntech.uwe.ac.uk/neuroanatomy/neuro4_1.h
tm
10
Swelling vs Edema

• Swelling is increased intravascular volume
• Edema is increased extravascular fluid

11

• Blood
• 15-20 of the cardiac output
• 20-25 of all oxygen inspired
• 750cc/min
• 80 from carotid arteries
• 20 from vertebral
• Circle of Willis is collateral circulation
• No sugar/fat/oxygen storage

12
Autoregulation

• When intra-cranial pressure begins to rise, the
  bodys own compensatory mechanisms include
  decreasing the production of CSF and restricting
  the blood flow to the brain
  (by vasoconstriction).

13
Autoregulation

• Self Regulated
• PCO2 (carbon dioxide) vasodilator
• For every 1mmHg change in PCO2 there is a 1-2cc
  change in blood flow per 100 GMs of brain
• Diameter of vessels
• Hypercapnia Increases CBF
• Hypocapnia Decreases CBF

14
Intercrainial Pressure Regulation

• When BP increases, cerebral arterioles constrict
  to keep blood entering brain at steady rate.
• When BP falls, cerebral arterioles dilate to
  increase blood flow to brain

15
Intercrainial Pressure Regulation

• Metabolic regulationchanges in O2 and CO2 Low
  O2 and increased CO2 cause vasodilation CSF
  regulationdecreased production or increased
  -reabsorption decreasing ICP.

16
Factors Affecting CBF

• Viscosity of the blood
• Seizures
• Anemia
• Drugs

17
CSF

• 125-150 cc clear fluid
• 500cc produced per day
• 20cc per hour
• Replaced 4-7 times per day
• Function
• Protection, cushions
• Waster disposal
• Nutritional support (2/3 bodies BS)

18
CSF Pressure

• Norm
• 1-15 mmHg or lt200mm H2O
• Low pressure
• Dehydration
• Increased pressure
• Valsalva
• Tumor, Subdural Hematoma, Subarachnoid
  Hemorrhage, Infections, Hydrocephalus

19
Symptoms of Increasing ICP

• Headache
• Visual changes
• Nausea
• Vomiting
• Behavior changes
• Changes in LOC
• Seizures

20
Symptoms

• Aniscoria
• Hemiparesis
• Vital sign changes
• Cushings Triad

21
http//learntech.uwe.ac.uk/neuroanatomy/neuro4_4.h
tm
22
Cushings Triad

• Vital Sign Changes in ICP
• Systolic pressure increases (widened pulse
  pressure results).
• Slowing of heart occursbradycardia (occurs as
  result of reflexive slowing in response to
  increased systolic pressure)
• Respiration changesbecomes slowed

23
Could it be?

• Difficulty speaking
• Blurred vision
• Hypertension
• Shallow rapid breathing
• Visual disturbances
• Paresthesia
• Hypoglycemia

24
OR?

• - Confusion
• Lethargy
• Nausea Vomiting
• Coma
• Seizures
• Syndrome of Inappropriate ADH

25
OR?

• Changes in LOC
• Nausea Vomiting
• Irritability
• Disorientation
• Personality changes
• Seizures
• Fluid Overload

26
OR?

• Street drug
• Alcohol withdrawal
• Over dose
• Diabetic ketoacidosis
• Hypervitiaminosis A
• Drug
• www.merck.com/mrkshared/mmanual/section1/chapter3/
  3c.jsp

27
Diagnosis of Increased Intracranial Pressure

• Overt symptoms
• Papilledema
• Nuchal rigidity
• Lumbar Puncture
• CT / MRI

28
Lumbar Puncture

• Contraindicated
• Focal signs
• Intracranial mass
• Papilledema
• Cardiorespiratory compromise
• Infection of skin

29
Rational for Contraindication

• A simple analogy

Performing a LP in the presence of I-ICP, may
result in herniation
30
Herniation

• Tentorium
• Midbrain and diencephalon through the
  tentorium
• Uncal
• Tonsillar
• Cerebellar tonsils
  through the foramen magnum

31
Diencephalic Stage

• Confused and drowsy
• Constricted pupils
• Gaze palsies

32
Mesencephalic Stage

• Unconscious
• Decerebrate posturing
• Dilated pupils
• Hyperventilation

33
Pontine Stage

• Unconscious
• Decerebrate posturing
• Constricted pupils
• Irregular breathing

34
Decorticate posture

• Indicated by rigidity, flexion of the arms,
  clenched fists, and extended legs. The arms are
  bent inward toward the body with the wrists and
  fingers bent and held on the chest. Presence of
  this type of posturing implies severe damage to
  the brain with immediate need for medical
  attention.

35
Decerebrate Posturing

• Internal rotation and extension of the arms
  lower limb extension
• Due to midbrain compression as the brainstem is
  further compressed

36
Medullary Stage

• Unconscious
• Flaccid
• Loss of homeostatic control
• Increase heart rate
• Decrease blood pressure
• Hyperthermia
• Cheyne-Stokes breathing

37
Cheyne-Stokes

• Breathing describes a waxing and waning
  ventilation, sometimes with periods of apnea,
  that occur in cycles.
• It is due to a delay in the medullary
  chemoreceptor response to blood gas changes

38
http//thediagram.com/3_6/
39
Biot's Respiration

• Biot's respiration, sometimes also called cluster
  respiration, is an abnormal pattern of breathing
  characterized by groups of quick, shallow
  inspirations followed by regular or irregular
  periods of apnea..
• Biot's respiration is caused by damage to the
  medulla oblongata due to strokes or trauma or by
  pressure on the medulla due to uncal or tentorial
  herniation. It generally indicates a poor
  prognosis

http//en.wikipedia.org/wiki/Biot27s_Respirations
40
(No Transcript)
41
(No Transcript)
42
Common Causes of I-ICP

• Vascular abnormalities
• AV malformations, aneurisms, stroke
• Diffuse cerebral ischemia
• Closed head trauma, shaken baby, vasospasm
• CNS infections
• Tumors
• Trauma
• Obstruction of CSF flow

43
Hydrochepalus
44
(No Transcript)
45
Intra Cerebral Hemorrhage
46
AV Malformation
47
Crainal Defect
48
Crainial defect with midline shift
49

• The Monroe-Kelle Hypothesis states that an
  increase in the volume of one component (blood,
  brain tissue, CSF) must be accompanied by a
  decrease in another component if intracranial
  pressure is to remain constant. The CSF and blood
  volume are the compartments that most easily
  change to accommodate changes in pressure. 
  Interventions to prevent secondary brain injury
  follows these principles and focuses primarily on
  cerebral blood flow and drainage. 

50
Management / Trauma

• Rapid transportation
• Early intubation
• Aggressive resuscitation
• Immediate CT
• ICP monitoring

51
CAT Scans

• Sensitivity for visualizing blood approximately
  96
• Visualizes
• Fractures
• Hematomas

52
Operative Management

• Burr holes
• Intra-operative ultra sound
• Surgical evacuation of mass lesion
• Craniotomy
• Craniectomy
• Ventricular drainage

http//www.trauma.org/neuro/neuromonitor.html
53
Medical Management

• Adequate cerebral perfusion
• Dehydration
• Hypovolemia
• Hypoxia
• Hyperventilation
• Sepsis
• Normal or hypothermia
• Hyperthermia causes increased cellular metabolism
  (10-13), increased lactic acid production,
  increased CO2 (vasodilatation)

54
Osmotic DiureticsMannitol

• Reduces ICP in 5-10 min. trough osmotic gradient
• BBB must be intact
• Removes H2O not Na
• Caution with
• Hypotension
• Coagulopathy
• CHF

55
Duiretics

• Furosemide (lasix)
• Loop of Henle, blocks transport of Cl Na
• Reduced CSF production 40-70
• Postssium depletion

56
Other Medications

• Corticosteroids
• H2 Blockers
• Sedation to control agitation, reduces metabolic
  needs
• Analgesia
• Barbiturates to suppress seizures, decreases
  metabolic needs, vasoactive effects

57
Hypothermia

• Decreased cellular metabolism
• Brain temp is 2.0o F higher than body
• Reduces inflammatory process
• Reduces cerebral metabolism
• Limits secondary brain injury

58
Nutrition

• Energy requirement 125-200 ABOVE normal
• Early feeding has a favorable effect on survival
• TPN PPN

59
Nursing Care

• Assessment
• Touch
• Oxygen
• Control pain
• Medicate prior to administering care
• Break up activities

60
Care

• Decrease stimulation
• Positioning
• Bowel
• Bladder

61
Glascow Coma Scale
62
(No Transcript)
63
Statistics

• Kills 160,000 yearly
• 4.7 million survivors living
• 2/3 with disabilities

64
CVA

• Sudden numbness or weakness of the face, arm or
  leg, especially on one side of the body
• Sudden confusion, trouble speaking or
  understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of
  balance or coordination
• Sudden, severe headache with no known cause

65
Act F.A.S.T

• FACE    Ask the person to smile.Does one side of
  the face droop?
• ARMS    Ask the person to raise both arms.Does
  one arm drift downward?
• SPEECH  Ask the person to repeat a simple
  sentence.Are the words slurred?  Can he/she
  repeat the sentence correctly?
• TIME    If the person shows any of these
  symptoms, time is important. 

66
Causes

• Risks that cannot controlled
• Increasing age
• Sex
• Race
• Family history of stroke

67
Causes

• Risks that can be controlled with Medical
  Treatment Lifestyle Changes
• High blood pressure
• Diabetes
• Cigarette smoking
• TIA
• High blood cholesterol
• Obesity
• Heart Disease

68
Women and Stroke

• Twice as many women die of stroke than breast
  cancer every year.
• More women than men will die from stroke.
• ½ of all African American women will die of
  Stroke or Heart Disease
• Migraine headaches can increase the risk 3-6
  times

69
Women

• If she smokes and takes BCP stroke risk increases
  34 times
• Postmenaposal women with a waist size greater
  than 35.2 inches trigliceride greater than 128
  mg/L, may have a 5 fod increase risk for

70
African Americans

• Twice as likely to die from stroke as
  Caucasians. 
• African Americans are affected by stroke more
  often than any other group.

71
African Americans

• 1 in 3 African Americans suffer from high blood
  pressure.
• Diabetes.  People with diabetes have a higher
  stroke risk.
• Sickle cell anemia.  If sickle-shaped cells block
  a blood vessel to the brain, a stroke can result.
• Higher incidence than Caucasians of obesity and
  smoking,

72
Kids and Stroke

• The incidence of stroke in children is relatively
  low -- about three cases in every 100,000
  children per year.  Strokes are slightly more
  common in children under the age of two.
• Causes
• birth defects
• infections (eg, meningitis, encephalitis)
• trauma
• blood disorders such as sickle cell disease

73
BP

• 120/80
• 140/90

74

• www.nlm.nih.gov/medlineplus/ency/imagepages/17133.
  htm

75
Treatment

• t-PA
• Given within 3 hours of onset
• 55 no residual
• 1 in 3 receive t-PA (50 are eligible)
• 12 24 hour arrival

www.nlm.nih.gov/medlineplus/ency/imagepages/17133.
htm
76
Hemorrhagic Stroke
www.nlm.nih.gov/medlineplus/ency/imagepages/17133.
htm
77
www.nlm.nih.gov/medlineplus/ency/imagepages/17133.
htm
78
www.nlm.nih.gov/medlineplus/ency/imagepages/17133.
htm
79
Left Brain Injury

• Speech and Language deficits
• Behavioral style
• slow
• cautious
• Memory deficits
• language

80
Left Brain Injury
81
Right Brain Injury

• Spatial Perceptual deficit
• Behavioral Style
• Quick
• Impulsive
• Memory deficit
• Performance

82
RightBrain Injury
83
Deficits After a Stroke

• Aphasia
• Global
• Expressive
• Receptive
• Apraxia inability to
• Carry out a spontaneous movement
• Remember orders or instructions
• To identify objects and will misuse them
• Willfully perform acts
• Agraphia

84
Deficits After a Stroke

• Dysarthria
• Difficulty in speech articulation due to
  impairment of muscles
• Dysphasia
• Impairment of speech resulting from a brain
  injury
• Dysphagia
• Inability to swallow

85
Deficits After a Stroke

• Impulsivity
• Hemiplegia
• Mood Changes

86

• www.rad.usuhs.mil/rad/herniation
• www.thridage.com/health/adam/ency/article
• www.homestead.com/emguidemaps/files/coma.html
• www.classes.kuma.edu/sm/nurs420
• www.emguidemaps.homestead.com/files/anisocoria.htm
  l
• 6. www.annals.org/cgi/content/full/130
  /5/427/F1
• www.med.harvard.edu/AANLIB/home.html
• http//thediagram.com/3_6/
• National Stroke Association
• http//www.ninds.nih.gov/disorders/stroke/knowstro
  ke.htm