Management Intra Cranial Pressure (Icp)

MANAGEMENT INTRA CRANIAL
PRESSURE (ICP)
Pembimbing : dr. Ita Muharram Sari, Sp.S
Presenter : dr. Heru Pranata
Dr. Nurdiansyah
 Intracranial compliance
 The Monro-Kellie doctrine states that the intracranial
 This intracranial space has three components: brain tissue, blood, and cere-
brospinal fluid (CSF). In an average adult, the brain tissue volume is 1,400
mL; the blood volume is 150 mL; and the CSF volume is 150 mL.3 Normal ICP
ranges 3-15 mmHg; in the intensive care unit (ICU), ICP values less than 20
mmHg are generally accepted.
 Pathologic states within the intracranial vault result in an increase of volume. This is a result of at
least one of the following: 1) extrinsic mass lesion, 2) increase in blood volume, 3) increase in CSF
volume, or 4) increase in brain tissue.
 To maintain normal ICP in these pathologic states, there is a reduction in the volume of other
compartments as a compensatory mechanism. As this compensatory mechanism reaches its limit,
the compliance (delta V/delta P) drastically. As compliance decreases, there is a greater the change
in pressure for a given change in volume (i.e., there are dramatic changes in pressure for small
incremental changes in volume; Fig. 1). This is re- flected in the ICP waveform as seen in Fig. 2.
 Cerebral perfusion pressure (CPP) is defined as mean arterial pressure (MAP) minus intracranial
pressure (i.e., CPP=MAP-ICP). Therefore as ICP rises, CPP will fall. Nor- mal CPP is 60-150 mm
Hg.8 CPP less than 60 mmHg may result in ischemic brain injury, while CPP greater than 150 mmHg
can lead to hyperemia and hyperperfusion injury.
 ICP MONITORING MODALITIES
 External ventricular drain
 An external ventricular drain (EVD) is a catheter inserted into one of the

lateral ventricles and connected to an external transducer via tubing filled
with saline.
 Intraparenchymal pressure monitor
 Intraparenchymal pressure monitors are placed into the brain tissue via a
burr hole and secured using bolt.
TREATMENT OPTIONS FOR ACUTE
INTRACRANIAL HYPERTENSION
 Many treatment options exist to treat acute intracranial hypertension. The

goal of these therapies is to decrease ICP to less than 20mm Hg; however,
the most recent TBI guidelines from the Brain Trauma Foundation (BTF) sug-
gest that the ICP goal should be less than 22 mmHg.
 Prior to proceeding through the algorithm, a set of general mea- sures

should be considered. These include elevation of the head of bed to 30°,
position of the head in a midline position, initiation of seizure prophylaxis,
volume resuscitation, avoidance of hyperglycemia and hyperthermia.
 Step 1. Surgical decompression
 Step 2. Sedation
 Step 3. Cerebral perfusion pressure optimization
 Step 4. Hyperventilation and vasoconstriction
 Step 5. Osmotherapy
 Step 6. Hypothermia and targeted temperature modulation
 Step 7. Barbiturate coma

 ICP and CPP monitoring are most frequently studied in TBI, but can play a
similar role in conditions such as SAH and ICH among other disorders.
 The threshold that defines intracranial hypertension is uncertain but

generally is considered to be greater than 20–25 mmHg, although both
lower and higher thresholds are described . The rec- ommendations for an
optimal CPP have changed over time and may in part be associated with the
variability in how mean arterial pressure (MAP) is measured to determine
CPP and depend on disease state
 ICP treatment is important and is best guided by ICP monitoring, clinical
imaging, and clinical evaluation used in combination and in the context of a
structured protocol [41–43]. We recognize that this may vary across
different diagnoses and different countries. Today, a variety of other
intracranial monitoring devices are available, and ICP monitoring is a
mandatory prerequisite when other intracranial monitors are used, to
provide a framework for optimal interpretation.
 1. ICP and CPP monitoring are recommended as a part of protocol-driven
care in patients who are at risk of elevated intracranial pressure based on
clinical and/or imaging features. (Strong recommendation, moderate quality
of evidence.)
 2. We recommend that ICP and CPP monitoring be used to guide medical

and surgical interventions and to detect life-threatening imminent
herniation; however, the threshold value of ICP is uncertain on the basis of
the literature. (Strong recommendation, high quality of evidence.)
 3. We recommend that the indications and method for ICP monitoring
should be tailored to the specific diagnosis (e.g., SAH, TBI,
encephalitis). (Strong recommendation, low quality of evidence.)
 4. While other intracranial monitors can provide useful information, we

recommend that ICP monitoring be used as a prerequisite to allow
interpretation of data provided by these other devices. (Strong
recommendation, moderate quality of evidence.)
 We recommend the use of standard insertion and maintenance

protocols to ensure safety and reliability of the ICP monitoring
procedure. (Strong recommendation, high quality of evidence.)
5. Both parenchymal ICP monitors and external ventricular catheters (EVD) provide reliable and accurate
data and are the recommended devices to measure ICP. In the presence of hydrocephalus, use of an
EVD when safe and practical is preferred to parenchymal monitoring. (Strong recommendation, high
quality of evidence.)
6. We recommend the continuous assessment and monitoring of ICP and CPP including waveform quality
using a structured protocol to ensure accuracy and reliability. Instantaneous ICP values should be inter-
preted in the context of monitoring trends, CPP, and clinical evaluation. (Strong recommendation, high
quality of evidence.)
7. While refractory ICP elevation is a strong predictor of mortality, ICP per se does not provide a useful
prognostic marker of functional outcome; therefore, we recommend that ICP not be used in isolation as a
prognostic marker. (Strong recommendation, high quality of evidence.)

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MANAGEMENT INTRA CRANIAL

 The Monro-Kellie doctrine states that the intracranial

 External ventricular drain

 An external ventricular drain (EVD) is a catheter inserted into one of the

 Intraparenchymal pressure monitor

 Many treatment options exist to treat acute intracranial hypertension. The

 Prior to proceeding through the algorithm, a set of general mea- sures

 Step 3. Cerebral perfusion pressure optimization

 Step 4. Hyperventilation and vasoconstriction

 Step 6. Hypothermia and targeted temperature modulation

 Step 7. Barbiturate coma

 The threshold that defines intracranial hypertension is uncertain but

 2. We recommend that ICP and CPP monitoring be used to guide medical

 4. While other intracranial monitors can provide useful information, we

 We recommend the use of standard insertion and maintenance

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