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Neurology > 2(E): Raised ICP > Flashcards

2(E): Raised ICP Flashcards

1
Q

What is normal range ICP

A

5-15mmHg

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2
Q

What ICP is considered raised

A

Above 20mmHg

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3
Q

What 4 focal mass effects cause raised ICP

A

Bleed: extradural, SAH
Intracranial tumour
Abscess
Hydrocephalus

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4
Q

What diffuse mass effective lead to raised ICP

A

Vasogenic oedema
Cytogenic oedema
Ischemic stroke
Meningitis

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5
Q

What is cytogenic oedema

A

Accumulation fluid in brain parenchyma due to build up Na+ and H2O

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6
Q

What is vasogenic oedema

A

Build-up fluid in interstitial space

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7
Q

What causes oedema

A

Ischaemic Strokes

Meningitis

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8
Q

Explain ‘early’ clinical-presentation of raised ICP

A
  • Headache: worse in mornings, on sneezing, coughing, moving head
  • Vomiting
  • Lethargy
  • Altered mental state
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9
Q

What are late clinical symptoms of raised ICP

A
  • Continuous vomiting
  • CN3 Palsy
  • Decrease in GCS
  • Cushing’s triad (bradycardia, HTN, irregular respiration)
  • Coma and death
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10
Q

What may be seen on fundoscopy in raised ICP

A

Papilloedema

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11
Q

What doctrine explains why raise in ICP can cause herniation

A

Monroe-Kellie doctrine

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12
Q

What is uncal herniation also called

A

Trans-tentorial

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13
Q

What is trans-tentorial herniation

A

Uncus of hippocampus is forced under tentorium

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14
Q

What are three signs of transtentorial herniation

A
  • CN3 Palsy
  • Ipsilateral weakness
  • Occludes PCA - causing ischaemic stroke of occipital lobe = homonymous hemianopia with macula sparing
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15
Q

How does CN3 palsy present

A
  • Fixed Mid-Dilated Pupil

- Eye deviated down and out

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16
Q

What is central herniation

A

Diencephalon passes through tentorium

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17
Q

How does central herniation present

A

Sunset eyes

  • Paralysis of upward gaze meaning eyes appear downwards
  • Lower eyelid may cover lower half of pupil
  • Only sclera is visible between pupil and upper eyelid
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18
Q

When is sunsetting of the eyes particularly common

A

Children with raised ICP

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19
Q

What is cingulate herniation also known as

A

Subfalcrine

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20
Q

What is sub-falcine herniation

A

Herniation of cingulate gyrus through fall cerebri

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21
Q

What does sub-falcrine herniation cause

A

Compress ACA causing ischaemic stroke

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22
Q

What is upward cerebellar herniation

A

Vermis is pushed upwards through transtentorium

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23
Q

What is tonsillar herniation

A

Herniation cerebellar tonsils through foramen magnum

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24
Q

How does tonsillar herniation present

A
  • Compress brainstem causing respiratory and cardiac dysfunction
  • Headache, neck stiffness
  • Drop in GCS
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25
Q

What are indications for ICP monitoring

A
  • Hydrocephalus
  • TBI
  • High-risk hydrocephalus (SOL, IIH, SAH, Reye’s)
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26
Q

What are contraindications for ICP monitoring

A

Anticoagulation

Brain abscess

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27
Q

What are the three types of ICP monitoring

A

EVD
Subarachnoid bolt
Extradural bolt

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28
Q

What is external ventricular drain also known as

A

Fluid-filled transducer ventriculostomy

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29
Q

What is gold-standard for ICP monitoring

A

EVD

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30
Q

What is the advantage of external ventricular drain

A

Able to drain CSF

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31
Q

Where is EVD placed

A

Kocher Point

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32
Q

What is the advantage of subarachnoid bolt

A

Less invasive than EVD

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33
Q

What is the problem with subarachnoid bolt

A
  • High infection risk

- Limited therapeutic use

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34
Q

What is advantage of epidural bolt

A
  • Less Infection risk then subarachnoid bolt
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35
Q

What is problem with epidural bolt

A
  • Limited use
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36
Q

If raised ICP is suspected, how should patient be approached

A

A-E
IV Access
O2 if required
Basic investigations to determine cause

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37
Q

If GCS less than 8, how is patient managed

A
  • Nurse at 30’
  • Anaesthetist to intubate

Treat ICP if signs herniation:

  • Mannitol or Hyper-osmotic Saline
  • Hyperventilation (Ambubag)
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38
Q

If GCS is more than 8 in suspected raised ICP what is ordered

A

CT Scan to identify lesion

39
Q

If lesion is identified on CT what should be done

A

Dexamethasone and refer to neurosurgery

40
Q

Define idiopathic intracranial HTN (Bening intracranial HTN)

A

Raised in ICP (above 20mmHg) with no hydrocephalus or mass present

41
Q

What demographic is IIH more common in

A

Obese women 15-45 years

Especially if gained weight quickly

42
Q

What are 3 broad risk factors for IIH

A
  • Pregnant
  • Obese
  • Medications
43
Q

What 5 medications increase risk of IIH

A
  • Lithium
  • Steroids
  • Vitamin A
  • GH
  • Tetracycline
44
Q

How does IIH present clinically

A
  • Headache: may be associated with nausea and vomiting
  • Visual changes
  • CN6 Palsy
45
Q

What visual changes may occur in IIH

A
  • Enlarged blind spot
  • Blurred vision
  • Papilloedema
46
Q

How does CN6 Palsy present

A

Horizontal diplopia - due to inability to abduct

47
Q

What will be seen on ophthalmoscopy in IIH

A

Bilateral papilloedema

48
Q

What should be ordered in all cases of IIH and why

A

MRI - Identify and exclude structural lesions

49
Q

Aside from MRI, what other investigation may be performed in IIH

50
Q

What will be seen on LP in IIH

A

Opening pressure of more than 26

51
Q

What indicates a very raised opening pressure

52
Q

What conservative management is indicated for IIH

A

Weight Loss

Medication review

53
Q

What medical management is indicated for IIH

A

Acetazolamide

Topiramate

54
Q

Why may topiramate be beneficial

A

Also helps with weight loss

55
Q

What surgical management may be indicated for iIH

A
  • Optic nerve sheath decompression

- VP Shunt

56
Q

Define hydrocephalus

A

Dilation of ventricles, due to accumulation of CSF

57
Q

What are the two types of hydrocephalus

A
  1. Obstructive (Non-communicating)

2. Non-Obstructive (Communicating)

58
Q

What is communicating hydrocephalus also know as

A

Non-obstructive

59
Q

What causes communicating hydrocephalus

A

Increase CSF production

Decrease CSF reabsorption

60
Q

What is obstructive hydrocephalus also known as

A

Non-Communicating

61
Q

What is obstructive (non-communicating hydrocephalus)

A

Obstruction to CSF Flow

62
Q

What is hydrocephalus ex vacuo stand for

A

Compensatory enlargement of ventricles secondary to brain atrophy

63
Q

In communicating hydrocephalus, what can increase CSF production

A

Chorioid carcinoma

Chorioid papilloma

64
Q

In communicating hydrocephalus, what are 3 causes of decrease CSF absorption

A
  • Inflammation: eg. meningitis
  • Haemorrhage: SAH or IV
  • Congenital absece arachnoid villi
65
Q

Why does SAH and IV Haemorrhage cause decreased absorption of CSF

A

Leads to fibrosis which can occlude arachnoid villi

66
Q

In obstructive hydrocephalus, how may causes be divided

A

Congenital

Acquired

67
Q

What are two congenital causes of obstructive hydrocephalus

A
  • Dandy-Walker Malformation

- Arnold-Chiari Malformation

68
Q

What is a dandy walker malformation

A

Congenital malformation due to failure fourth-ventricle to close

69
Q

What are 3 acquired causes of obstructive hydrocephalus

A
  • Brain tumour
  • SAH or IV Haemorrhage
  • Inflammaiton: post-meningitis
70
Q

Overall, how does hydrocephalus present clinically

A

Symptoms raised ICP

  • Morning Headache
  • N+V
  • Drop in GCS
  • Cushing’s Reflex When Severe
71
Q

When does the anterior fontanelle close in infants

72
Q

Explain symptoms raised ICP in children

A
  • As anterior fontanelle has not closed head has room to expand causing MACROCEPHALY
  • The open anterior fontanelle may feel tense and BULDGE
  • Compression of superior colliculus due to raised ICP causes upward gaze palsy presenting as sun-setting eyes
73
Q

What are sunsetting eyes

A

Individual has upward gaze palsy meaning pupils appear as if facing downwards. The lower eyelid may cover half of the pupil. Only sclera can be seen between pupil and upper eyelid

74
Q

In infants under 6-months, what is used to identify hydrocephalus

75
Q

What is used for children with suspected hydrocephalus

76
Q

What will be seen on CT/MRI in obstructive hydrocephalus

A

Dilation of ventricles superior to the obstruction

77
Q

What will be seen on CT/MRI in non-obstructive hydrocephalus

A

Dilation of all ventricles

78
Q

When should an LP only be performed in hydrocephalus

A

If communicating (Non-obstructive) hydrocephalus

79
Q

What is first-line for acute hydrocephalus

A

External ventricular drain

Drains into bag beside the bed-side

80
Q

Where is external ventricular drain inserted

A

Right lateral ventricle

81
Q

What is long-term management for hydrocephalus

82
Q

What is normal pressure hydrocephalus

A

Communicating hydrocephalus with normal opening pressure

83
Q

In which age-group does normal pressure hydrocephalus occur

A

Over 60’s

84
Q

What is the mnemonic to remember symptoms in normal pressure hydrocephalus

A

Wet, Wacky, Wobbly

85
Q

What triad of symptoms occurs in normal pressure hydrocephalus

A
  • Urinary Incontinence
  • Ataxia
  • Dementia
86
Q

Why does wet occur

A
  • Dilation of ventricles disrupts the cona radiata causing urinary incontinence
87
Q

What is wacky section of normal pressure hydrocpephalus

88
Q

What is wobbly section of normal pressure hydrocephalus

A
  • Ataxia

- Wide based gait with small steps

89
Q

How will gait appear in normal-pressure hydrocephalus

A

Wide base, small-steps

90
Q

How will normal pressure hydrocephalus present on CT or MRI

A

Enlarged fourth ventricle

91
Q

What is a arnold-chiari malformation

A

Herniation cerebellar tonsils, vermis and medulla through foramen magnum

92
Q

When will arnold-chiari symptoms manifest

93
Q

What does Arnold chair malformation cause

A
  • Obstructive hydrocephalus (due to stenosis cerebral aqueduct)
  • Feeding difficulties
  • Breathing difficulties
94
Q

What are Arnold chiari malformations associated with

A

Myelomeningocele

Syringomyelia

Neurology (26 decks)

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