INTRACRANIAL PRESSURE ( #ICP ) MEASUREMENT & HOW IT CAN GUIDE THERAPY❓

🔸ICP data can be used to 

✔️predict outcome and evolution of intracranial pathology
✔️calculate and manage cerebral perfusion pressure (CPP) [without an ICP monitor, CPP is not known]. 
✔️direct management strategies, and 
✔️limit the use of potentially deleterious therapies.
🔸Cerebral herniation is a pressure issue and an ICP monitor may allow early detection; it is preferable to avoid herniation than to treat it
🔸Information from an ICP monitor may provide useful information to guide patient care. For example, a patient with a worrisome-appearing CT scan who does not have intracranial hypertension may not require the same degree of treatment as a patient with a similar scan but elevated ICP. Similarly, a patient with elevated ICP that is refractory to escalating management becomes an early candidate for “second tier” treatments or if very high, even withdrawal of care.
🔸ICP values have prognostic value and so it can guide management and discussions with the family about outcomes
🔸Even transient episodes of severely raised ICP and ischemia can be devastating to the traumatized brain, making it critical to accurately and continuously monitor ICP & CPP. Because insertion of intraparenchymal ICP monitors is safe, the ability to monitor CPP per se is a supportable argument for widespread ICP monitoring.
🔸Perhaps more important than a single ICP threshold may be a trend over time, ICP waveform analysis, or whether the ICP value is associated with other detrimental effects.
🔸When both ICP and brain oxygen are treated, the outcome may be better than if just ICP is treated after TBI
🔸The ICP waveform is a modified arterial pressure tracing
🔸 It has 3 peaks: P1, P2 & P3
🔸 P1 is a result of transmitted pressure from choroid plexus
🔸 The amplitude of P2 changes with brain compliance. If compliance is poor, amplitude will be high ( can even exceed that of P1) and vice versa
🔸P3 represents the dicrotic notch
🔸 Lundberg (A) or Plateau waves are steep rise of ICP to over 50 mm of Hg and lasting for 5-20 minutes; then it falls abruptly. Are always pathological and indicates significantly reduced compliance
🔸 Lundberg (B) waves are oscillations occurring every 1-2 minutes where ICP rises to over 20-30 mm of Hg from baseline in a crescendo manner. They are supposed to be result of altered cerebral (B)lood volume and altered tone of cerebral (B)lood vessels 
🔸 Lundberg (C) waves are oscillations whose amplitude is less than that of B waves and are supposed to result because of interactions between cardiac and respiratory (C)ycles. They occur also in healthy individuals 
METHODS OF MEASUREMENT OF ICP
➿ Intraventricular catheter – ventriculostomy represents the “gold standard” for pressure measurement

 

✔️Normally placed in the frontal horn of lateral ventricle 
✔️Allows therapeutic CSF drainage 
✔️Creates a pathway for infection 
✔️In case of the Integra Neuroscience external drainage catheter, ICP readings are based on a fluid-filled transduction system that transmits changes in ICP through a saline-filled tube to a diaphragm on a strain gauge transducer. This monitor must be leveled with the foramen of Monro (approximately the level of the external auditory canal) after insertion and should be zero-balanced daily. The level of the drain can be adjusted to allow more or less CSF drainage.
 ➿Subdural bolt / Catheters
✔️ less invasive 
✔️ Bolts commonly use fiberoptic technology that allows continuous ICP monitoring without CSF drainage. The fiberoptic type of catheter can be placed in the subdural space or in the brain parenchyma
✔️ Usually subdural space over frontal lobe of non-dominant hemisphere is selected
✔️ Prone to signal damping and calibration drift 
✔️ Potential risk of infection 
✔️ Doesn’t require penetration of brain tissue
✔️Camino Post Craniotomy Subdural Pressure Monitor utilizes the craniotomy bur holes and flap as a point of entry. The monitor is zero-balanced and then tunneled under the scalp toward the craniotomy bur hole of choice and positioned in the subdural space. This monitor contains a microtransducer at the tip, which is similar to the OLM ICP monitor ( see below)
✔️Gaeltec ICT/B pressure sensor is intended to monitor ICP subdurally. It contains a balloon-covered pressure sensor that is activated when filled with air. This monitor is self–zero-balanced in vivo and is reusable. 
➿Intracerebral transducer 
✔️Parenchymal devices are easier to place, particularly when altered ventricular anatomy may limit ventricular catheter placement.
✔️However, intraparenchymal fiber-optic and electronic strain gauge systems are more expensive and cannot be recalibrated once in situ
✔️Inability to check zero calibration & drain CSF 
✔️ Risk of infection
✔️Less reliable
✔️The Camino OLM ICP monitor measures ICP in the intraparenchymal tissue or subarachnoid space. It contains a transducer at the distal tip, thus measuring pressure without a fluid-filled system. The catheter is secured to the skull through an adjustable bolt, allowing placement at variable depths (up to 5 cm).
✔️The Codman Microsensor catheter can be used as an intraparenchymal or intraventricular monitor, depending on the depth of the catheter
✔️ Spiegelberg ICP monitors measure ICP through an air-pouch system attached to a pressure transducer connected to an electronic device. The probes differ, depending on where they rest (Epidural or Intraparenchymal)
🔸The incidence of infection ~ 2-7% with monitoring ≥ 5 days
🔸The risks are slightly greater with dural penetration 
🔸The zero reference point of the transducer is usually taken as the external auditory meatus 
🔸 Rather than the waveform type, the important factors appear to be the degree and duration of ICP elevation
🔸Two emerging non-invasive ICP monitoring methods include measuring the optic nerve sheath diameter (ONSD) as seen on an ultrasound probe placed on the superolateral aspect of the orbit and the pulsatility index (PI) which is cal- culated from transcranial Doppler studies (TCD).
#NeuroAnesthesia , #anaesthesia , #TheLayMedicalMan , #NeuroCriticalCare , #CriticalCare , #NeuroICU

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