Treatment of increased intracranial pressure (ICP intracranial pressure) in benign and malignant cases

A brain injury or another medical condition can cause growing pressure inside your skull. This dangerous condition is called increased intracranial pressure (ICP) and can lead to a headache. The pressure also further injure your brain or spinal cord. This kind of headache is an emergency and requires immediate medical attention. The sooner you get help, the more likely you are to recover.

 what is ICP?

The pressure within the cranium that is exerted by the combined total volume of the 3 components within the skull.Brain tissue, blood volume and CSF volumes are in a state of dynamic equilibrium. If an increase occurs in any of the them, the volume of one or more of the other components must decrease or an elevation of ICP will result.

 Causes of ICP

ICP can become elevated for various reasons in response to disease, environment, emotion and normal bodily functions .Factors can be non-pathologic or pathologic in nature.

Non-pathological causes

• Coughing
• Sneezing
• Lifting
• Bending
• Valsalva (bearing down)
• Stress
• Blood pressure changes
• Emotional responses
• Body positioning

 Pathological causes 

• Aneurysm rupture and subarachnoid hemorrhage
• Brain tumor
• Encephalitis irritation and swelling, or inflammation, of the brain
• Head injury
• Hydrocephalus (increased fluid around the brain)
• Hypertensive brain hemorrhage (bleeding in the brain from high blood pressure)
• Intraventricular hemorrhage (bleeding into the fluid-filled areas, or ventricles, inside the brain)
• Meningitis  (infection of the membranes covering the brain and spinal cord)
• Subdural hematoma  (bleeding between the covering of the brain and the surface of the brain)
• Epidural hematoma  (bleeding between the inside of the skull and the outer covering of the brain)
• Seizure
• Stroke

Symptoms of ICP

Symptoms of increased ICP can vary depending on their cause. They often depend on where a tumour, a blockage, an injury or swelling is in the brain. Symptoms may be mild at first and become worse as the pressure in the skull increases.

A headache is the most common symptom of increased ICP. It is often worse in the morning or after strenuous activity. Report headaches and the following symptoms to your doctor or healthcare team as soon as possible:

• nausea
• vomiting
• dizziness
• behaviour changes
• poor memory
• restlessness
• nervous system problems, including weakness, numbness, vision problems, coordination problems, loss of muscle strength, loss of movement (paralysis) or difficulty speaking
• lowered consciousness, including drowsiness, lack of energy, confusion or coma

complications

ICP has serious complications, such as:

• Seizures
• Stroke
• Neurological damage
• Death

diagnose 

To diagnose ICP, your doctor may do the following:

• Medical history and physical exam including a neurological exam to test senses, balance and mental status
• Spinal tap (also called lumbar puncture), which measures the pressure of cerebrospinal fluid
• tomography (CT) scan, the gold standard imaging test, creates a series of cross-sectional
• X-ray images of the head and brain
• Magnetic resonance imaging (MRI) (used after the initial assessment)uses magnetic fields to detect subtle changes in brain tissue content and can show more detail than X-rays or CT)

treatments

Increased intracranial pressure is an emergency. Treatment might include:

Positioning

Normally the head needs to be slightly elevated and the neck is kept straight. In this position decreasing of any intracranial pressure by letting blood and cerebrospinal fluid drain from the brain.

Restriction of fluids

It can be essential to limit any fluids to the individual. The brain is like a sponge and it swells after absorbing any extra fluid. So, limiting fluids may help to manage the swelling and ICP.

Medications

There are different types of medication used in the treatment of brain swelling and ICP. These include:

• Diureticsused to reduce the quantity of water in the body. This causes less fluid accessible to the brain for swelling.
• Anticonvulsant medicationsare used to stop or prevent seizures. Seizures normally occur due to any extra electrical activity in the brain. There are many types of seizures. The most common types cause the individual to have movements of the legs as well as the arms to have jerking movement followed by sleep.
• Barbituratesare given when the individual’s intracranial pressure to extremely high and very hard to control. This medication put the individual into a deep sleep normally called a barbiturate coma. This can help stop more damage from swelling.

Osmotherapy

When your brain swells, it accumulates excess fluid. Osmotherapy is a technique meant to draw water out of the brain. This is done using osmotic agents such as mannitol, or high-salt saline. Osmotic therapy also helps improve blood circulation. This will help reduce swelling and ICP in the skull.

Hyperventilation

Some doctors may perform a controlled hyperventilation to help lower your ICP. Hyperventilation causes you to exhale more than you inhale, lowering the amount of carbon dioxide in your bloodstream. Proper blood flow in your brain is dependent upon carbon dioxide. Controlling this process lowers the blood flow in your brain and reduces ICP.

Hypothermia

Another treatment method includes inducing hypothermia. Lowering the body temperature decreases metabolism in the brain and can also reduce swelling and ICP.

VP shunt placement

This is a more invasive procedure that involves draining fluid from the brain.

Procedure 

Doctors typically perform the placement of a VP shunt while a patient is under general anesthesia. You’ll be asleep during the surgery and won’t experience pain. The entire procedure takes about 90 minutes. The surgical nurse will shave the area behind your ear in preparation for shunting, as this is where they will place the catheter. Catheters are thin, flexible tubes used to drain excess fluid. A surgeon will make a tiny incision behind the ear and will also drill a small hole in the skull. They will then thread one catheter into the brain through this opening. The other catheter goes behind your ear and is subcutaneous, meaning it resides under the skin. This tube travels down to your chest and abdomen, allowing excess CSF to drain into the abdominal cavity, where your body absorbs it. Your surgeon may attach a tiny pump to both catheters and place it under the skin behind your ear. The pump will automatically activate to remove fluid when the pressure in the skull increases. It may even be possible to program the pump, also called a valve, to activate when the fluid increases to a certain volume.

Recovery

Recovery from a VP shunt placement takes three to four days. Most people can leave the hospital within seven days after the procedure. During your hospitalization, the hospital staff will monitor your heart rate and blood pressure, and your doctor will administer preventive antibiotics. Your doctor will make sure the shunt is working properly before you leave

Risks of VP shunting

Placement of a shunt is a very safe procedure. However, complications can occur during or after the procedure. Risks associated with any surgical procedure include excessive bleeding and infection. You might also experience adverse reactions to anesthesia, such as breathing difficulties, changes in heart rate, or changes in blood pressure levels.

There are rare risks specific to VP shunting that can be serious and potentially life-threatening if left untreated, including:

• infection in the shunt or brain
• blood clots
• bleeding in the brain
• damage to brain tissue
• swelling of the brain

Surgery

In more severe cases of cerebral edema, you may need surgery to relieve ICP. This surgery could mean removing part of the skull or removing the source of the swelling, such as in the case of a tumor. The goal is to remove as much of the cancer as possible without causing damage to the healthy parts of the brain. While the location of some tumors allows for easy and safe removal, other tumors may be located in an area that limits how much of the tumor can be removed. Even partial removal of brain cancer can be beneficial.

Prevention

While ICP cannot be prevented, some of its leading causes like head injury often can. Wearing a protective helmet when playing contact sports or riding a bike, buckling a seat belt, moving the seat in the car far away from the dashboard, and using a child safety seat can preventing head injuries from becoming life-threatening. Removing clutter from floors and keeping them dry will help to prevent falls at home–a common cause of head injury in the elderly.

frequently asked questions

What decreases intracranial pressure?

As a result, CPP can be reduced from an increase in ICP, a decrease in bloodpressure, or a combination of both factors. Through the normal regulatory process called pressure autoregulation, the brain is able to maintain a normal cerebral blood flow (CBF) with a CPP ranging from 50 to 150 mm Hg

What is the normal intracranial pressure? 

The normal ICP is 5 - 15 mmHg. There is no defined set point at which treatment for intracranial hypertension should be initiated, but levels above 20mmHg are usually treated. However it is probably more important to maintain an adequate cerebral perfusion pressure.

What is CSF? 

Cerebrospinal fluid, or CSF, is clear, colorless, and filtered from the blood by cells in the ventricles (fluid spaces). The body produces 500 ml/day, but reabsorption is slower, so only 100-150 ml is found circulating around the brain and spine. CSF flows from the ventricles to the subarachnoid space, which is a space between the covering membranes, and then around the brain and spine where it is reabsorbed by openings in the membrane (arachnoid granulations).