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Raised ICP (Aetiology (Idiopathic Hydrocephalus Status epilepticus,…
Raised ICP
Aetiology
Idiopathic
Hydrocephalus
Status epilepticus
Neoplastic
Primary CNS tumour
Metastasis
Lymphoma
Trauma
Head trauma
Infection
Meningitis
Encephalitis
Abscess
Vascular
Haemorrhage (SDH, EDH, SAH, ICH)
CVST
Pathophysiology
Fixed vol cranium
Increase in contents e.g. SOL, oedema,
CSF obstruction causes increased pressure
Normal ICP <15 mmHg
Clinical
presentation
N+V
Reduced conciousness/
confusion
Headache
Character
Radiation
Nil
Onset
Sudden/insidious
Associated symptoms
N+V, reduced GCS, vision
Timing
Persistent
Site
Diffuse head
Exacerbating/relieving factors
Exacerbating - lying down, bending, coughing
Relieving - sitting/standing up
Diagnosis
Examination
Cardio - low HR, high BP (Cushing's response)
Resp - Cheyne-Stokes breathing
Neuro - low GCS, pupil const/dilat, reduced acuity
Fundo - papilloedema
Investigations
Bedside
Obs - low HR, high BP, fever if infection
ECG - may show bradycardia
Bloods
FBC (WCC if infection), CRP (high if infection),
U+Es, LFTs, clotting, glucose, blood cultures
Toxicology screen
Imaging
CXR - infection e.g. TB
CT head - SOLs
MRI/MRA/MRV if needed
LP
If no ventricle enlargement
Opening pressure, cytology, MCS,
WCC, glucose, protein, lactate
History
PC: trauma, fever, rash, red flags
PMH - epilepsy, cancer
DH - anticoagulants, allergies
FH - haemorrhages, cancer
SH - travel, smoking, alcohol
Complications
(herniation syndromes)
Cerebellar
tonsil
Pressure in posterior fossa compresses cerebellum,
tonsils forced through the foramen magnum
Clinical presentation
CN VI palsy
Ataxia
Upgoing plantars
Cheyne-Stokes breathing
Coma
Apnoea
Subfalcine/
singulate
Pathophysiology
Frontal mass forces cingulate gyrus
through the falx cerebri
Silent or compress ACA (stroke)
Clinical presentation
Asymptomatic
Stroke - contralateral hemiparesis
Uncal
Pathophysiology
Lateral supratentorial mass pushes uncus
of temporal lobe through the temp incisura
Compresses CN III, cerebral peduncle
(hemiparesis), and midbrain RAS (coma)
Clinical presentation
Ipsilateral CN III palsy
Ophthalmoplegia
Contralateral hemiparesis
Coma
Management
Initial ABCDE
Definitive
Medical
Hyperventilate O2
MOA: reduces PaCO2 thus cerebral
vasoconstriction, reducing ICP rapidly
Mannitol
MOA: osmotic agent, reduces oedema
SE: rebound raised ICP if used >12h
Steroids
Indication: oedema around tumour only
MOA: reduce tumour-assoc inflammation
Surgical
Craniotomy
Burr hole
Conservative
Monitoring (obs, neuro obs, GCS)
Fluid restrict 1.5L
Identify and treat cause
Referral
Neurosurgery ASAP
Definition
Neurological disorder of high ICP
resulting in headache, vomiting,
reduced GCS and papilloedema