Increased intracranial pressure

Question 1

What are the differentials for increased ICP?

Answer 1

Hydrocephalus
Intracranial hemorrhage
Brain tumor
CNS infection

Question 2

HYDROCEPHALUS

Answer 2

Pathophysio
- Results from an impaired circulation and/or absorption
of CSF and/or increased production of CSF by choroid
plexus papilloma
- Inc adrenergic stimulation, dec CSF production
Inc cholinergic stimulation, inc CSF production
- CSF is produced in the choroid plexus epithelium
within the cerebral ventricles
- CSF is re-absorbed in the arachnoid villus cells (located
in the superior sagittal sinus) and returned to the
blood stream within the vacuoles (pinocytosis)

Question 3

Discuss the CSF flow

Answer 3

CSF Flow: “Come Let Me Treat Sisa For Lunch Maybe Somewhere
in Ayala”
Produced in the choroid plexus –> Lateral Ventricle –> foramen of Monroe –> third ventricle –> aqueduct of Sylvius –> fourth
ventricle –> Luschka and Magendie –> subarachnoid space where
it is absorbed in the arachnoid granulations

Question 4

Most common nonobstructive
hydrocephalus

Answer 4

Subarachnoid hemorrhage

Question 5

What are the types of hydrocephalus?

Answer 5

COMMUNICATING OR NONOBSTRUCTIVE

-obliteration of subarachnoid cisterns and/or malfunction of subarachnoid villi

Etiologies:
Achondroplasia
basilar impression
benign enlargement of subarachnoid space
choroid plexus papilloma
meningeal malignancy
meningitis
posthemorrhagic

NONCOMMUNICATING OR OBSTRUCTIVE
-obstruction within the ventricular system

Etiologies:
Aqueductal stenosis
mitochondrial
autosomal recessive or dominant
L1CAM mutations
Chiari malformations
Dandy-Walker malformations
Klippel-Feil Syndrome

Question 6

What are the clinical manifestations of hydrocephalus?

Answer 6

CM
1. Infants: accelerated rate of head enlargement (HC>CC,
HC >2SD in growth chart)
2. Wide bulging anterior fontanel
3. Older children: headache
4. Eyes may deviate downward due to impingement of
the dilated suprapineal recess on the tectum (setting
sun sign)
5. Pyramidal/ Long tract signs (brisk DTRs/ hyperreflexia,
spasticity, clonus, Babinski, weakness)
6. Percussion of skull produce a “cracked pot” sensation
or Macewen sign (separation of sutures)
7. Foreshortened occiput (Chiari malformation)
8. Prominent occiput (Dandy-Walker malformation)

Question 7

What are the diagnostics?

Answer 7

Dx
1. Plain skull films – show separation of sutures
2. CT, MRI, UTZ – most impt to ID abnormality that causes
hydrocephalus. Ventricular enlargement caused by
excess CSF

Question 8

Management of hydrocephalus

Answer 8

Mgt
Depends on etiology
1. Acetazolamide 20 mkd q8 IV/po, may inc until 100 mkd
2. Furosemide 1-2 mkdose q6-12: temporary relief by
reducing rate of CSF production
3. Extracranial shunts
o Most common complication: Staphylococcal
epidermidis infection

Question 9

INTRACRANIAL HEMORRHAGE

Answer 9

CH ?: INTRACRANIAL HEMORRHAGE
- Intracerebral hemorrhage (ICH)
- Pathologic accumulation of blood within the cranial
vault occurring within the brain parenchyma or
surrounding meningeal spaces
Etiolopatho
- Nontraumatic (hypertension, drug abuse), rupture of
AVM, coagulopathy, tumor, infection, trauma
- High mortality rate
- Accompanying edema. Disrupt and compress adjacent
brain tissue à displacement of parenchyma à inc ICP
à fatal herniation syndromes
CM
1. Alteration of consciousness
2. Nausea, vomiting, headache, sz
3. Focal neurologic deficits
4. Hypertension
5. Nuchal rigidity, anisocoria
Dx
1. CBC– monitor and assess Hct, plt to ID hemorrhagic
risk and complications, ID anemia
2. PT, PTT – ID coagulopathy
3. E’s, toxicology screen – ID metabolic derangements:
hypoNa, monitor osmolarity for osmotic diuresis
4. CT scan/MRI, CT angiography – hyperdense signal
intensity. Multifocal hemorrhages at the frontal,
temporal, and occipital poles (traumatic). ID AVMs and
cavernous angiomas
Mgt
1. Refer to neurosx
a. Ventriculostomy
b. Endoscopic hematoma evacuation