increased intracranial pressure

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INCREASED INTRACRANIAL PRESSURE

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Page 1: Increased Intracranial Pressure

INCREASED INTRACRANIAL PRESSURE

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• Increased intracranial pressure is a rise in the pressure inside the skull that can result from or cause brain injury.

• Alternate Names : ICP, Intracranial pressure - increased, Intracranial hypertension, Acute increased intracranial pressure, Sudden increased intracranial pressure

• Icp is normally 7-15 mmHg

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Subdural hematoma develops when blood vessels that are located between the membranescovering the brain (the meninges) leak blood after an injury to the head. This is a serious condition since the increase in intracranial pressure can cause damage to brain tissue and loss of brain function.

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CAUSES

• Increased intracranial pressure can be due to a rise in pressure of the cerebrospinal fluid. This is the fluid that surrounds the brain and spinal cord. Increase in intracranial pressure can also be due to a rise in pressure within the brain itself. This can be caused by a mass (such as a tumor), bleeding into the brain or fluid around the brain, or swelling within the brain itself.

• An increase in intracranial pressure is a serious medical problem. The pressure can damage the brain or spinal cord by pressing on important brain structures and by restricting blood flow into the brain.

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DIAGNOSTICS AND LAB EXAMS

• PHYSICAL EXAMINATION– BP– Temperature (if elevated must consider brain abscess or

encephalitis)– Examine for neck stiffness which may indicate subarachnoid

hemorrhage but may also indicate cerebral abscess or encephalitis– Examine for papilledema which may suggest cerebral abscess,

brain hemorrhage or brain tumor– Full neurological examination, including cranial nerve examination,

visual fields and visual acuity, pupils reaction to light, eye movements, sensation and motor power of face and limbs

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• Radiological investigations– Skull X-Ray, if history of head injury– CT Scan of brain, if suspected brain tumor, subarachnoid

hemorrhage, brain abscess– Radioisotope brain scan, may be indicated to localize

specific brain tumors and haematomas (blood clots)– MRI scan of brain, may be necessary if need more

discrimination of brain masses– Cerebral angiography, may be required to rule out

arteriovenous malformations and to define site or blood supply of a brain mass

– Chest X-Ray to look for lung cancer, if brain tumor is diagnosed (lung cancer is the most common cause of brain cancer)

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EEG-• may show electrical abnormalities in the region

of the brain mass (but it may be normal). A cerebral abscess shows characteristic wave changes.

• Note: Lumbar puncture if suspected any mass lesion, lumbar puncture is Contra-indicated .

• Intracranial pressure may be measured during a spinal tap (lumbar puncture). It can also be measured directly by using a device that is drilled through the skull or a tube (catheter) that is inserted inside the brain.

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Increased intracranial pressure Assessment Questionnaire

• Is the raised intracranial pressure acute or chronic?• Symptoms of raised intracranial pressure?Why: e.g. any headache,

however mild, that is present on or soon after waking and which is made worse by coughing, straining or sneezing. The headaches usually increase in severity and frequency with the passage of time. May be accompanied by morning vomiting. Drowsiness is a late feature.

• Is the person a infant with a large head?Why: indicates probably hydrocephalus (a group of conditions characterized by an increase in cerebrospinal fluid volume associated with elevated intracranial pressure and dilatation of the brain ventricles) e.g. Dandy-Walker syndrome, Arnold Chiari syndrome.

• History of head injury?Why: traumatic injury to the brain may cause increased intracranial pressure due to swelling of the brain or subdural or extradural haematoma.

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• History of drowning?Why: drowning causes lack of oxygen to the brain and consequent hypoxic brain injury which may cause brain swelling and increased intracranial pressure.

• History of "near-miss" sudden infant death syndrome?Why: causes lack of oxygen to the brain and consequent hypoxic brain injury which may cause brain swelling and increased intra-cranial pressure.

• Past medical history?Why: e.g. some medical conditions may increase the risk of benign intracranial hypertension including hypothyroidism, hyperthyroidism, hypoparathyroidism, Addison's disease, Cushing's syndrome, sarcoidosis, systemic lupus erythematosus.

• Medications?Why: e.g. some medications may increase the risk of benign intracranial hypertension including oral contraceptive pill, corticosteroids, supplemental vitamin A, tetracycline, nitrofurantoin, lithium, indomethacin, phenytoin.

• Impairment of consciousness?Why: i.e. drowsiness progressing to stupor and coma - may suggest a mass in the brain that is placing pressure on the brain stem.

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• Seizures?Why: may suggest a mass in the brain, whether malignant or benign.

• Limb paralysis?Why: may occur on the opposite side to the brain mass (due to direct effect of mass) or on the same side of brain mass due to compression of the brain stem due to increased intracranial pressure.

• Symptoms of mastoiditis?Why: e.g. pain, swelling and tenderness developing behind the ear associated with general deterioration in well-being and mucous to pus-like ear discharge - Mastoiditis may be complicated by intracranial venous sinus thrombosis which can cause raised intracranial pressure.

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SIGNS AND SYMPTOMSInfants:• Drowsiness• Separated suture on the skull• Bulging of the soft spot on top of the head (bulging fontanelle)• VomitingOlder children and adults:• Behavior changes• Decreased consciousness• HA• Lethargy• Neurological symptoms, including weakness, numbness, eye movement

problems, and double vision• Seizures• Vomiting

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STAGES OF ICP• Stage 1- minimal increases in ICP due to

compensatory mechanisms.• Stage 2- compromise neuronal oxygenation

and systemic arteriolar vasoconstriction to increase mean arterial pressure (MAP) and Cerebral perfusion pressure (CPP)

• Stage 3- ICP approaches the MAP it becomes more difficult to squeeze blood into the intracranial space.

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TREATMENT

Treatment may include:• Breathing support• Draining of cerebrospinal fluid to lower pressure in

the brain (EVD)• Medications to decrease swelling (antihypertensive,

diuretics)• Rarely, removal of part of the skull• If a tumor, hemorrhage, or other underlying problem

has caused the increase in intracranial pressure, the cause should be treated as appropriate.

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PROGNOSIS

• Sudden increased intracranial pressure is a serious and often deadly condition. If the underlying cause of the raised intracranial pressure can be treated, then the outlook is generally better.

• If the increased pressure pushes on important brain structures and blood vessels, it can lead to serious, permanent problems or even death.

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POSSIBLE COMPLICATIONS

• Death• Permanent neurological problems• Reversible neurological problems• Seizures• Stroke