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RAISED INTRACRANIAL
TENSION(PART – 1) D R . S I D D H A RT H B NORMAL VALUES CSF PRODUCTION
• Cerebrospinal fluid (CSF) is a clear, colourless
ultrafiltrate of plasma with low protein content (<40mg/dL - albumin)and few cells(3-5 lymphocytes).
• The CSF is mainly produced by the choroid
plexus, but also by the ependymal lining cells of the brain’s ventricular system RATE OF PRODUCTION AND ABSORPTION • Average rate of CSF formation is 21 to 22 mL/h (0.35 mL /min), or approximately 500 mL / day.
• Brain volume is normally approximately 1,400 mL.
• The entire reservoir of CSF is about 90 to 150 mL in the normal adult, of which approximately 75 mL is intracranial, 75mL is vascular. • Spinal CSF volume is about 50mL.
• Normal CSF pressure in recumbent position is 65 – 195
mm H2O • Resorption requires a positive pressure of atleast 60 mmH2O in the subarachnoid space. • CSF fills cerebral ventricles and subarachnoid spaces around the brain and spinal cord. • ISF(Interstitial fluid) circulates between the cells.
• Water moves into extracellular space along osmotic
gradient created at the Capillary – Abluminal surface with the help of Na+/K+ ATPase pump. • Glucose by Glut1 – Cerebral blood vessels Glut3 – neurons Glut5 - microglia NEUROVASCULAR UNIT
• NEURONS, ASTROCYTES AND PERICYTES comprise
the Neurovascular (Gliovascular)Unit • Total surface of capillary endothelial cells forms the major interface between Blood and Brain. (others – choroid plexus and arachnoid granulations). • At each of the above BBB interfaces, high resistance junctions between cells exist – TIGHT JUNCTIONS. (OCCLUDIN, CLAUDIN) • These impede non lipid soluble substances, charged substances, large molecules. • On the abluminal surface of endothelial cells – thin layer of basal lamina Type 4 collagen binding sites for Laminin and fibronectin; act as barriers to charged particles by heparan sulphate • Entactin connects type 4 collagen and Laminin – gives structure to capillary. • Fibronectin from cells joins basal lamina to endothelium
• Within the basal lamina – pericyte smooth
muscle + macrophage TIGHT JUNCTION • Zona occludins tether tight junction proteins to Actin in the endothelium. • Occludin attaches to zona occludin • Claudin attach to occludin and protrude into clefts between cells – ZipLocked
• After injury, astrocytes release HYALURON
impedes movement of fluids in extracellular space and slows tissue repair. LET’S DO THE MATH!
• Remember OHM’S LAW?
• E = IR
• Pcsf – Pv = I0 * R • In the steady state, this flow rate is equal to the rate of CSF production (0.3 mL/min). • R0, the resistance to absorption, which under normal circumstances is approximately 2 .5
• P csF = P v + I x R0. • The product of I x R0 is only 0.8 mm Hg • The main contribution to CSF pressure-as measured by spinal puncture-is the Venous Pressure MONROE KELLIE DOCTRINE
• Total volume of fluid and tissue contained within the
skull is constant.
• The intact cranium and vertebral canal, together
with the relatively inelastic dura, form a rigid container, such that an increase in the volume of any of its contents-brain, blood, or CSF-will elevate the ICP. • Furthermore, an increase in any one of these components must be at the expense of the other two CEREBRAL EDEMA
radicals) disruption of BBB expansion of extracellular space. • Protein and blood products enter brain tissue Increase oncotic pressure.
• Steroids suppress expression of MMPs and other
inflammatory mediators. CYTOTOXIC EDEMA
• Pathological process that damages cell
membranes (activation of MMP2, MMP3,MMP 9,COX2) constricts extracellular space.
• Stroke causes failure of ATP pumps Increase in
brain water. • Seen within 24 – 72 hours after a stroke.
• IntraCerebral Hemorrhage causes both Cytotoxic
and Vasogenic edema( mass effect and release of toxic blood products) TREATMENT
• Reduction of volume in one of the 3
compartments-
1. Blood Volume – hyperventilation
2. CSF Volume – placing ventricular drains 3. Brain volume – mannitol(0.25-1g/kg) • Steroids lower ICP in Vasogenic edema – reduce blood vessel permeability. • CONTRAINDICATED in treatment of edema secondary to stroke/ hemorrhage • Edema surrounding brain tumours respond particularly well( Take contrast enchanced images before giving steroid – closure of BBB – enhancement of lesion can be missed) BASIS FOR MRI
• Resonance signals detected by MRI are from
water molecule protons. • Cytotoxic edema SHRINKS extracellular space – restricts diffusion of water APPARENT DIFFUSION COEFFICIENT (ADC) shows a loss of signal appears BLACK on MRI, Whereas the DIFFUSION WEIGHTED IMAGE (DWI) has a BRIGHT signal (within minutes of cerebral ischaemia)
• Dark ADC + Bright DWI = INFARCT
CEREBRAL PERFUSION PRESSURE
• The numerical difference between ICP and mean
BP within the cerebral vessels
• normal value is 60 to 100 mm Hg
• When these compensatory mechanisms have been exhausted, ICP rises rapidly with further increases in volume until it reaches the level comparable with the pressure inside of cerebral arterioles.
• At this point, the rise of ICP is
halted as cerebral arterioles begin to collapse and the blood flow completely ceases. • The relationship between ICP and CBF and functional effects was described thoroughly by Symon and colleagues, as follows: [32] • CBF of 50 mL/100 g/min: Normal • CBF of 25 mL/100 g/min: Electroencephalogram slowing • CBF of 15 mL/100 g/min: Isoelectric electroencephalogram • CBF of 6 to 15 mL/100 g/min: Ischemic penumbra • CBF of less than 6 mL/100 g/min: Neuronal death CAUSES OF RAISED ICT
