颅内高血压英文-课件.pptx

1、Intracranial Pressure PhysiologyMonro-Kellie Doctrine(1783/1824)1.Rigid container2.Liquid contents are incompressible3.Mass must be displacedIntracranial Pressure PhysiologyCranial ContentsTotal Volume 1300-1500 ccBrain 80%gray matter/white matterCSF 10%Intraventricular 50%75 ccSubarachnoid 50%75 cc

2、Blood 10%Arterial 30%45ccVenous 70%105ccIntracranial Pressure PathophysiologyBlood epidural,subdural,subarachnoid,intracerebral,intraventricular,intravascularTumorAbscess/InfectionForeign ObjectsAir pneumocephalusCranial RestrictionPagets disease,craniosynostosisHydrocephalus,Cysts,HygromaEdema Inte

3、rstitial e.g.CNS lymph system,brain as a sponge Cytotoxic dead/dying cells Vasogenic altered BBB,capillary breakdown,abscessIntracranial Pressure PathophysiologyMass DisplacementCSF Blood BrainICP/CPP 150125100755025002550Cerebral Perfusion Pressure(mm Hg)Cerebral Blood Flow(ml/100 g/min)Zone of Nor

4、mal AutoregulationMaximumConstrictionMaximumDilatationPassiveCollapse02550ICP(mm Hg)Vasodilatory Cascade ZoneAutoregulation Breakthrough ZoneStephan A.Mayer,MDIntracranial Pressure PhysiologyIntracranial Pressure PathophysiologyHerniation TypesStructureBarrierVesselSubfalcine cingulate g.falxACAUnca

5、l uncustentoriumPCATonsillarcerebellum foramen m.vert/bUpwardcerebellum tentoriumTranscalvarialcortexskullsurfaceIntracranial Pressure PathophysiologyHerniation Types1.Subfalcine2.Uncal3.tonsillarIntracranial Pressure PathophysiologyElevated ICP Clinical SymptomsHeadache-Aggravated by bending and st

6、ooping.Caused by distortion or irritation of pain sensitive areas in the dural coverings and blood vessels.Vomiting-Caused by compression or ischemia of brainstem.Usually occurs with lesions of the posterior fossa.This is usually the result of hydrocephalus and 4th ventricle dilation causing stimula

7、tion of the nucleus of vagus nerve.Personality and behavior changes-A depression in motor and thought processes that can lead to somnolence,and decreased level of consciousness and coma.Caused by compression on the reticular substance of upper brainstem and thalamus causes this phenomenon.Papilledem

8、a-this is usually the result of increased CSF pressure in the optic nerve sheath impeding venous drainage and axoplasmic flow in optic neurons.PapilledemaDeath 12 monthsPapilledemaElevated ICP Clinical SymptomsIntracranial Pressure PathophysiologyCerebral Perfusion Pressure(mm Hg)Severe disability o

9、r death 12 monthsIntracranial Pressure PhysiologyBUT MY BRAINS KEPT FALLING OUT George CarlinHemicraniectomyCaused by compression on the reticular substance of upper brainstem and thalamus causes this phenomenon.Mass DisplacementElevated ICP Clinical SymptomsSubarachnoid 50%75 ccTotal Volume 1300-15

10、00 ccCSF 10%AutoregulationThis is usually the result of hydrocephalus and 4th ventricle dilation causing stimulation of the nucleus of vagus nerve.Interstitial e.Hypertonic Saline(ml/100 g/min)Elevated ICP Clinical SymptomsCranial Neuropathy CN III or VICushings Triad Hypertension/Increased Pulse Pr

11、essure Bradycardia Irregular RespirationElevated ICP Clinical SymptomsICP MeasurementRadiographic Not particularly accurateOther Non-invasive Unproven:infra-red,laser,TCD(Pulsatility Index)Invasive Lumbar puncture OtherICP Measurement ICP TreatmentHead of Bed 30 degrees Improves venous drainageLasix

12、 Diuretic decreases intravascular volumeMannitol (older agents glycerol,urea)Osmotic diureticDiuretic decreases intravascular volumeOsmotic agent removes free water by osmosisViscosity improves micro-circulation ICP TreatmentSedation/Agitation Decrease unnecessarily elevated blood pressure and intra

13、vascular volumeIntubation/Hyperventilation Decrease pCO2(25-30 torr),change H+gradient at blood vessel causing vasoconstriction,leading to decreased intravascular volumeFever control Hyperthermia leads to increased cerebral blood flow and increased blood volumeICP TreatmentBarbiturate Coma Decrease

14、cerebral metabolic demandHypothermia Decrease cerebral metabolic demandHypertonic Saline Osmotic gradientsSurgeryElevated ICP TreatmentElevated ICP TreatmentI USED TO HAVE AN OPEN MIND BUT MY BRAINS KEPT FALLING OUT George CarlinHemicraniectomy TrialsDECIMAL-FranceDESTINY-GermanyHAMLET-NetherlandsCo

15、mbined AnalysisNIHSS 15MCA strokeWithin 45 hoursIntracranial Pressure PathophysiologyForeign ObjectsPapilledemaHypertension/Increased Pulse PressureElevated ICP Clinical SymptomsInterstitial e.This is usually the result of hydrocephalus and 4th ventricle dilation causing stimulation of the nucleus o

16、f vagus nerve.Air pneumocephalusElevated ICP TreatmentElevated ICP Clinical SymptomsMass must be displacedLiquid contents are incompressibleViscosity improves micro-circulationHead of Bed 30 degreesMass DisplacementDECIMAL-FranceIntracranial Pressure Physiology(ml/100 g/min)I USED TO HAVE AN OPEN MI

17、NDElevated ICP Clinical SymptomsCombined AnalysisSevere disability or death 12 months ARR 51.2%,p0.0001Death 12 months ARR 50.3%,p0.0001Elevated ICP TreatmentHemicraniectomyNovel Approaches to ICH/IVH Mass EffectAspiration+/-thrombolysis.This makes intuitive sense.Does it work?Intracranial Pressure

18、PathophysiologyMass DisplacementCSF Blood BrainElevated ICP Clinical SymptomsCranial Neuropathy CN III or VICushings Triad Hypertension/Increased Pulse Pressure Bradycardia Irregular RespirationElevated ICP TreatmentI USED TO HAVE AN OPEN MIND BUT MY BRAINS KEPT FALLING OUT George CarlinCombined Ana

19、lysisSevere disability or death 12 months ARR 51.2%,p0.0001Death 12 months ARR 50.3%,p 30 degreesIntracranial Pressure PathophysiologyCN III or VII USED TO HAVE AN OPEN MINDIntracranial Pressure PathophysiologyDecrease pCO2(25-30 torr),change H+gradient at blood vessel causing vasoconstriction,leadi

20、ng to decreased intravascular volumeUpwardcerebellumtentoriumDECIMAL-FranceUsually occurs with lesions of the posterior fossa.CSF 10%Air pneumocephalusIntracranial Pressure PhysiologyViscosity improves micro-circulation(ml/100 g/min)Decrease pCO2(25-30 torr),change H+gradient at blood vessel causing

21、 vasoconstriction,leading to decreased intravascular volumeIrregular RespirationArterial 30%45ccBUT MY BRAINS KEPT FALLING OUT George CarlinIntraventricular 50%75 ccBlood 10%Elevated ICP TreatmentViscosity improves micro-circulationViscosity improves micro-circulationBUT MY BRAINS KEPT FALLING OUT G

22、eorge CarlinAbscess/InfectionInterstitial e.Rigid containerSedation/AgitationIntracranial Pressure PathophysiologyCaused by compression on the reticular substance of upper brainstem and thalamus causes this phenomenon.Viscosity improves micro-circulationBradycardiaCerebral Perfusion Pressure(mm Hg)I

23、ntracranial Pressure PathophysiologyArterial 30%45cc(ml/100 g/min)Intracranial Pressure PathophysiologyBlood epidural,subdural,subarachnoid,intracerebral,intraventricular,intravascularCN III or VIBUT MY BRAINS KEPT FALLING OUT George CarlinElevated ICP TreatmentIntracranial Pressure PhysiologyIntrac

24、ranial Pressure PathophysiologyDoes it work?Mass DisplacementViscosity improves micro-circulationHemicraniectomyMannitol (older agents glycerol,urea)BUT MY BRAINS KEPT FALLING OUT George CarlinI USED TO HAVE AN OPEN MINDPersonality and behavior changes-A depression in motor and thought processes tha

25、t can lead to somnolence,and decreased level of consciousness and coma.Cranial NeuropathyICP Treatment(ml/100 g/min)CN III or VICombined AnalysisBlood epidural,subdural,subarachnoid,intracerebral,intraventricular,intravascularIntracranial Pressure PathophysiologyBlood 10%Sedation/AgitationElevated I

26、CP Clinical SymptomsOsmotic gradientsHeadache-Aggravated by bending and stooping.Sedation/AgitationElevated ICP TreatmentVomiting-Caused by compression or ischemia of brainstem.Caused by compression on the reticular substance of upper brainstem and thalamus causes this phenomenon.Rigid containerCran

27、ial NeuropathyOsmotic agent removes free water by osmosisViscosity improves micro-circulationICP TreatmentSedation/AgitationMannitol (older agents glycerol,urea)Arterial 30%45ccRigid containerOsmotic agent removes free water by osmosisElevated ICP Clinical SymptomsHyperthermia leads to increased cer

28、ebral blood flow and increased blood volumeHead of Bed 30 degreesIntracranial Pressure PathophysiologyI USED TO HAVE AN OPEN MINDViscosity improves micro-circulationTonsillarcerebellumforamen m.Hypertension/Increased Pulse PressureElevated ICP TreatmentTotal Volume 1300-1500 ccIrregular RespirationCranial NeuropathyRadiographic