Anesthesia

INTRACRANIAL HYPERTENSION

INTRACRANIAL HYPERTENSION Listen to Audio brain1_0.jpg -sustained ICP > 15 mmHg May results from: -expanding tissue mass or fluid volume -interference of the normal CSF absorption -excessive CBF -systemic derangement leading to cerebral edema ICP > 30 mmHg -leads to progressive decrease in CBF -viscous cycle occurs due to ischemia secondary to decreased CBF -resultant cerebral ischemia causes cerebral edema which again leads to inc ICP -viscous cycle continues: ↑ICP:↓CBF:↑cerebral ischemia:↑cerebral edema:↑ICP …brain herniation SYMPTOMS -headache -nausea and vomiting -papilledema -focal neurological deficits -altered mental status Cushings response: abrupt increase in ICP ( ≅ 1 – 15 mins) with bradycardia Cerebral Edema -increase in water content within the brain -due to disruption in the integrity of the blood brain barrier possible causes of cerebral edema include: -mechanical trauma -inflammatory lesions -brain tumors -hypertension -infarction TREATMENT goal: temporarily decrease brain edema and lower the ICP -correct underlying disorders -corticosteroids (ex dexamethasone) help promote repair of the blood brain barrier -fluid restriction reduce the amount of free water content within the brain -osmotic agents rapidly lowers ICP by affecting the serum osmolality -loop diuretics slowly decreases ICP and may decrease CSF production -hyperventilation (mild) relationship: ↓ PaC02: cerebral vasoconstriction: ↓CBF and ↓ICP osmotic diuresis ex. mannitol 0.25g- 0.5 g/kg -effective in rapidly reducing ICP -main effect on serum osmolality -desired serum osmolality 300 – 315 mOsm/L -weak vasodilation may cause a transient decrease in MAP disadvantages of mannitol: -possible transient increase in intravascular volume -may lead to pulmonary edema in cardiac and/or renal patients -may allow a hematoma to expand due to decreased volume of brain around the hematoma secondary to diuresis and dec ICP -rapid decrease in ICP in the elderly may lead to SDH due to rupture of the fragile bridging veins of the sagittal sinus loop diuretic ex. furosemide -less effective than osmotic diuresis (mannitol) -requires more time compased to osmotic diuresis (upto 30 minutes) -benefit may include directly decreasing the CSF production loop diuretic + osmotic diuretic synergistic use: -synergistic effect may be beneficial -closely monitor [K+]

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