INTRACRANIAL PRESSURE ABNORMALITIES

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INTRACRANIAL PRESSURE ABNORMALITIES

• Enrique De La Mora Glasker M.D.

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Intracranial hypertension

• Most oftenly associated with
• 1) Rapidly expanding mass lesion
• 2) CSF outflow obstruction
• 3) Cerebral venous congestion
• gt250 mm CSF manifestation of serious neurlogic
  disease
• Lumbar CSF pressure may not accurately reflect
  intracranial pressure (ICP)

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Signs of increase ICP

• Headache
• Papilledema most reliable sign of ICP
• If ICP approaches the systolic blood pressure,
  the cerebral perfusion pressure decreases and
  irreversible ischemia may develop

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Idiopathic intracranial hypertension

• A syndrome of increased ICP accompanied by
• No localizing neurologic signs
• No intracranial mass lesion
• No CSF outflow obstruction
• An alert, otherwise healthy-looking patient
• Almost always obese, oftenly female
• Can be associated with a variety of systemic and
  iatrogenic disorders
• Unknown cause

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Pathophysiology of idiopathic intracranial
hypertension

• Etiology is unknown, but is speculated as
• 1) increase in dural sinus venous pressure
• 2) increase in CSF outflow resistance
• 3) increased CSF formation rate
• 4) some combination of the above
• The constancy of obesity has sugested the
  possibility of hypothalamic disorder

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Clinical manifestation of idiopathic intracranial
hypertension

• Headache-most common
• Bilateral papilledema-almost always present
• Nausea/vomiting
• Visual disturbance
• Retro-ocular pain
• Diplopia
• Tinnitus
• vertigo

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Empty sella syndrome

• In Chronically increased ICP
• 1) radographically globular enlargement of the
  sellar turcica
• 2) incompetent diaphragma sellae
• 3) Compressed, but functioning pituitary gland

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Tx of idiopathic intracranial hypertension

• Four (4) general approaches
• 1.-repeated lumbar puncture
• 2.-Pharmacologic treatment
• 3.-Shunting (Ventriculosystemic or
  lumbo-peritoneal)
• 4.-incision of optic nerve sheath

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Hydrocephalus

• Net accumulation of CSF within the cerebral
  ventricles and their consequent elargement
• CSF pressure is frequently normal (or low) in
  chronic hydrocephalus

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Hydrocephalus classification

• 1.-Obstructive
• A.-non- communicating
• Caused by lesions obstructing intracerebral CSF
  circulation at or proximal to foramina of Luschka
  and Magendie.
• B.-Communicating
• Caused by obstruction of basal cisterns or
  convexity subarachnoid space with ventricular
  system communicating with spinal subarachnoid
  space, but CSF cannot drain through arachnoid
  villi into superior sagital sinus
• 2.-Non-obstructive

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Hydrocephalusacute vs. chronic

• Complete ventricular outflow obstruction
• Acute hydrocephalus
• Coma
• (death)
• Aqueductal stenosis
• Complications of subarachnoid hemorrhage
• Chronic hydrocephalus

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Chronic hydrocephalus

• In many instances, the cause of symptomatic
  chronic hydrocephalus cannot be determined.
• (Normal pressure hydrocephalus)

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Clinical manifestations of hydrocephalus

• Acute obstructive hydrocephalus
• Severe headache
• Lethargy
• Signs of increased ICP
• Papilledema
• Abducens palsy
• Signs of causative lesion
• Hypereactive reflexes
• Bilateral extensor planter responses

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Clinical manifestation of hydrocephalus

• Chronic communicating hydrocephalus
• Progressive dementia
• Unsteady gait
• Urinary incotinence
• Bilateral pyramidal and extrapyramidal signs

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Tx of hydrocephalus

• Acute hydrocephalus
• Ventricular drainage and CSF diversion

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Intracranial hypotension

• Low or zero lumbar CSF pressure (nl70-200 mm CSF
  5-15 mm Hg)

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Intracranial hypotension

• CSF fìstula
• Post-Lumbar puncture drainage
• Spontaneus-idiopathic, dural nerve sheath tear.
• Sever throbbing fronta and occipital headache
• Within 30 sec. After changing posture to erect
• Subsides completely when lying flat
• (dizzines, nausea, stiff neck, Photophobia)

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Intracranial hypotension

• Spontaneous intracranial hypotension is rare.
• Unknown etiology
• Spontaneous recovery in days to a few weeks.

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Tx of intracrania hypotension

• Epidural blood patch
• Injection of 10 ml of patients own blood into
  the epidural space

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