MANAGEMENT OF RAISED INTRACRANIAL PRESSURES

SR NEUROSURGERY SGPGIMS LUCKNOW

1. Management of raised Intracranial pressure and related factors Presenters :Dr. Yashveer Singh Dr.Arif Rasool Moderator : Dr.Mohd.Sadik Akhtar Co-moderators : Dr.M.F.Huda

2. GOAL OF MANAGEMENT Keep ICP <20 mm Hg. Keep CPP >70 mm Hg. Avoid CCP < 50 mmHg. So in order to avoid CPP <50 mmHg , it may be best to start treatment when CPP falls <60 mmHg

3. GENERAL MEASURES Head End elevation . Keep neck straight and avoid any constriction band. Avoid hypotension. Control hypertension. Avoid Hypoxia (pO2 <60 mmHg). Ventilate to normocarbia (Pco2 35-40 mmHg). Light Sedation. Prophylactic hypothermia. NCCT Head

4. ELEVATING HEAD END 30-45 degree Position above heart and prevent kinking or compression of jugular vein Decrease venous outflow resistance [CSF] Intracrainal compartment Spinal compartment Reduces MAP at Carotid level

5. KEEP NECK STRAIGHT, AVOID ANY CONSTRICTION BAND Care should be taken to avoid obstruction of cerebral venous return by cervical collars or endotracheal tube ties. Keep the head maintained in the neutral position.

6. CONTROL BLOOD PRESSURE Avoid hypotenstion (SBP < 90 mmHg) Normalize blood volume Use pressors if needed Control hypertension Nitroprusside Beta blockers ( labetalol …) Avoid overtreatment ( Hypotension)

7. AVOID HYPOXIA (PAO2 <60 mmHg) PaO2 shouldn’t fall below 60mmHg and Sat <90%. Maintain airways. Supplementary oxygen.

8. NORMOCARBIA (PACO2=35-40 mmHg) PaCO2 should be maintained around 35-40 mmHg CO2 retention leads to vasodilatation leading to increased flow hence increased ICP.

9. LIGHT SEDATION Calm the patient → Restricted movements → Decrease in the ICP → Controls sudden bursts of rise in ICP. Codeine =30-60 mm IM q 4hrs Lorazepam 1-2 mg IV q 4-6 hrs

10. PROPHYLACTIC HYPOTHERMIA Controversial. Decreased metabolic demand for O2 (CMRO2). 32-35 degree centigrade. > 48 hrs

11. SPECIFIC MEASURES FOR CONTROL OF RAISED INTRACRANIAL HYPERTENSION Loss of previously controlled ICP. Patients not improving clinically. Patient is deteriorating.

12. Heavy sedation. Drainage of CSF. Osmotic therapy Mannitol Hypertonic saline Furosemide Hyperventilation. EEG

13. HEAVY SEDATION When patient is agitated. To blunt the elevation of ICP that occur with certain maneuvers . Drugs: MgSO4= 2-4 mg/hr IV. Fentanyl = 2-5 µg/kg/hr IV. Sufentanil = 10-30 µg test dose f/b 0.05-2 µg/kg/hr IV. Propofol drip= 0.5mg/kg test dose f/b 20-70 pg/kg/min IV. Low dose pentabarbitral =100 mg IV q 4hrs. Vecuronium = 8-10 mg IV q 2-3 hrs.

14. CSF Drainage In conditions where intracranial catheter is placed CSF can be drained out in controlled manner to reduce intracranial pressure. 75 ml of CSF every 8 hrs should be drained. (450-700 ml CSF per day in patients where none of the CSF is absorbed) Drip chamber is at ≤ 10 cm above EAC.

15. OSMOTIC THERAPY Mannitol . Furosemide . Hypertonic saline.

16. MANNITOL Indications Sign of trans- tentorial herniation . Progressive neurological deterioration.

17. MANNITOL-MECHANISM 1. Lower ICP Plasma expansion reduce hematocrit Increase CBF and O2 delivery. ICP decreased with in few minutes (CPP< 70 mmHg). Increased serum tonicity Draw edema fluid from cerebral parenchyma’ Decreased ICP in 15-30 minutes and effect last for 1.5-6 hrs.

18. 2. Supports microcirculation by improving blood rheology 3. Free radical scavenging. Dose = 0.25-1 gm/kg body weight bolus over <20 minutes then 0.25 mg/kg over 20 minutes q 6hrs.

19. CAUTIONS Open ,cross BBB and may draw fluid in to CNS. Cortocosteroids+Phenytoin+Mannitol NKH. Excessively vigorous bolus HTN If autoregulation defective ↑CBF and may promote herniation . High dose risk of renal failure.

20. FUROSEMIDE Increased serum tonicity ↓ Cerebral edema ↓ ICP. Slow the production of CSF. Dose = 10-20 mg IV q 6hrs. Hold serum osmolarity >320 mOsm /L.

21. HYPERTONIC SALINE(HS) May reduce ICP in patients refractory to mannitol . Dose = 3% saline at 25-50 ml/hr IV continuous infusion (Peripheral line). = 7.5-23.4% saline must be given through a central line. HS should be discontinued after 72 hrs to avoid rebound edema . Serum osmolarity >320 mOsmol /L. No improvement in outcome over mannitol has been demostrated .

22. HYPERVENTILATION(HPV) HPV ↓ PaCO2 Cerebral vasoconstriction ↓CBF Shift blood from normal area to area of decreased blood flow ↓CBV ↓ICP Focal ischemia in area with preserved blood flow

23. GUIDELINE FOR HPV 1. In the absence of sign of intra-cranial hypertension, chronic prolonged HPV ( PaCO2 ≤ 25 mmHg) should be avoided. 2. Prophylactic HPV ( ≤ 25 mmHg ) is not recommended. 3. HPV for brief periods ( minutes) Prior to insertion of ICP monitor (Sign of raised ICP). After insertion of monitor (Sudden ↑ ICP and/or acute neurological deterioration).

24. 4. HPV for longer period Raised ICP not responded to Sedation, paralysis, CSF drainage and osmotic diuretics. 5. HPV may be appropriate for raised ICP resulting from hyperemia .

25. Recommendation for PaCO2 following head trauma PaCO2 ( mmHg) 35-40 30-35 25-30 <25 Description Normocarbia , use routinely Hyperventilation. Augmented hyperventilation. Aggressive hyperventilation

26. HPV MUST BE WEANED SLOWLY Reducing PaCO2 from 35-29 mmHg lowers ICP 25-30% Onset of action=30 sec. Peak= 8 minutes. Effect may be blunted by = 1 hr. After which it is difficult to return normocarbia without rebound elevation of ICP.

27. CAVEATS OF HPV HPV should be avoided during first 5 days after Head trauma ( specially first 24 hrs). Do not use prophylactically . If documented raised ICP is un-responsive to other measures, hyperventilate only to PaCO2=30-35 mmHg. If prolonged HPV to PaCO2=25-30 mmHg is deemed necessary, consider monitoring SjVO2,CBF to rule-out cerebral ischemia

28. SURGICAL TREATMENT Any subdural or epidural hematoma larger than ≈ 1 cm maximal thickness should be removed. In cases of contusion showing progressive deterioration the contused parts need to be surgically removed

29. EDH Surgical indications: EDH > 30 cc (regardless of GCS). It is strongly recomended that patient of acute EDH with GCS <9 with Anisocoria undergo urgent surgical evacuation.

30. SDH Evacuated regardless of GCS: Acute SDH Thickness >10mm. MLS > 5mm (on CT Scan). Acute SDH with Thickness < 10mm and MLS < 5 mm should undergo surgical evacuation if: GCS drops by ≥ 2 point from the time of injury to admission. Pupil are asymetric or fixed and dilated. ICP>20 mmHg.

31. Chronic SDH surgical evacuation of hematoma indicated if Focal deficit, mental status changes Maximal thickness >1 cm

32. Chronic SDH Surgical evacuation of hematoma indicated if Focal deficit, mental status changes Maximal thickness >1 cm

33. Traumatic posterior fossa mass lesions Symptomatic posterior fossa mass lesions or those with mass effect on CT Scan should be surgically removed. Most parenchymal hemorrhage managed non-surgically were < 3cm in diameters

34. Hemorrhagic contusion Progressive neurological deterioration referable to traumatic intra-cerebral hemorrhage , medically refractory IC-HTN or sign of mass effect on CT Scan. Traumatic intra-cerebral hemorrhege volume> 50 cc GCS = 6-8 with frontal or temporal traumatic intra-cerebral volume > 20cc with MLS ≥ 5mm and or compressed basal cisterns on CT Scan

35. Traumatic cerebral edema Decompressive craniectomy with in 48 hr of injury for patient with diffuse, medically refractory post traumatic cerebral edema associated with IC-HTN. Decompressive craniectomy for patients with refractory IC-HTN and diffuse parenchymal injury and radiographic evidence for impending trans- tentorial herniation

36. DECOMPRESSIVE CRANIECTOMY Removal of a large area of skull to increase the potential volume of the cranial cavity Control raised ICP Improve  cerebral perfusion pressure Cerebral blood flow   Control brain edema

37. SHUNTS V-P Shunt V-A Shunt Torkildsen shunt Lumboperitoneal Cyst or subdural shunt Miscellaneous shunt Pleural space Gall bladder Ureter and Urinary blader

38. SUPPORTIVE TREATMENT Prophylaxis against ulcer: Antacids/ H2 blockers :Ranitidine 50mg IV q 8hr. IV Fluids: NS+20meq/L. : Avoid hypotonic solutions (RL). Arterial line for B.P. monitoring and frequent ABG. Aggressive control of fever. CVP line or peripheral arterial line if high dose of mannitol are needed. Glycemic control, neither hypo nor hyperglymia should be allowed as both of them are detrimental to brain parenchyma.

39. STEPS RATIONALE Head End elevation . 30-45 degree Decrease venous outflow resistance [CSF] Intracrainal compartment to Spinal compartment Keep neck straight and avoid any constriction band Keep the head maintained in the neutral position Avoid hypotension Normalize blood volume,Use pressors if needed Control hypertension. Nitroprusside ,Beta blockers ( labetalol ) , Avoid overtreatment ( Hypotension) Avoid Hypoxia (pO2 <60 mmHg). PaO2 shouldn’t fall below 60mmHg and Sat <90%. Ventilate to normocarbia (Pco2 35-40 mmHg). PaCO2 should be maintained around 35-40 mmHg Light Sedation. Codeine =30-60 mm IM 4hrs,Lorazepam 1-2 mg IV 4-6 hrs Prophylactic hypothermia Controversial.,Decreased demand for O2 (CMRO2). Summary ( General measures )

40. Summary ( Specific measures ) STEPS RATIONALE Heavy sedation. When patient is agitated,To blunt the elevation of ICP that occur with certain maneuvers . Drainage of CSF Reduce intracranial pressure., 75 ml of CSF every 8 hrs should be drained, 450-700 ml CSF per day in patients where none of the CSF is absorbed) Osmotic therapy Lower ICP , Increase CBF and O2 delivery. Decrease cerebral edema Slow the production of CSF. Hyperventilation. HPV ↓ PaCO2 Cerebral vasoconstriction EEG Decompresive craniectomy