顱內(nèi)高血壓英文精選課件

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

2、ular 50% 75 ccSubarachnoid 50% 75 ccBlood 10%Arterial 30% 45ccVenous 70% 105ccIntracranial Pressure PhysioloIntracranial Pressure PathophysiologyBlood epidural, subdural, subarachnoid, intracerebral, intraventricular, intravascularTumorAbscess/InfectionForeign ObjectsAir pneumocephalusCranial Restri

3、ctionPagets disease, craniosynostosisHydrocephalus, Cysts, HygromaEdemaInterstitial e.g. CNS lymph system, brain as a spongeCytotoxic dead/dying cellsVasogenic altered BBB, capillary breakdown, abscessIntracranial Pressure PathophyIntracranial Pressure PathophysiologyMass DisplacementCSF Blood Brain

4、Intracranial Pressure PathophyICP/CPP 150125100755025002550Cerebral Perfusion Pressure (mm Hg)Cerebral Blood Flow (ml/100 g/min)Zone of Normal AutoregulationMaximumConstrictionMaximumDilatationPassiveCollapse02550ICP (mm Hg)Vasodilatory Cascade ZoneAutoregulation Breakthrough ZoneStephan A. Mayer, M

5、DICP/CPP 150125100755025002550CIntracranial Pressure PhysiologyIntracranial Pressure PhysioloIntracranial Pressure PathophysiologyHerniation TypesStructureBarrierVesselSubfalcine cingulate g.falxACAUncal uncustentoriumPCATonsillarcerebellumforamen m. vert/bUpwardcerebellumtentoriumTranscalvarialcort

6、exskullsurfaceIntracranial Pressure PathophyAutoregulation Breakthrough ZoneViscosity improves micro-circulationI USED TO HAVE AN OPEN MINDTotal Volume 1300-1500 ccDoes it work?ICP (mm Hg)Viscosity improves micro-circulationHemicraniectomy TrialsDecrease unnecessarily elevated blood pressure and int

7、ravascular volumeBradycardiaInterstitial e.Hypertension/Increased Pulse PressureCushings TriadDiuretic decreases intravascular volumeElevated ICP Clinical SymptomsICP (mm Hg)Intubation/HyperventilationDESTINY - GermanyHemicraniectomy TrialsIntracranial Pressure PathophysiologyHerniation TypesSubfalc

8、ineUncaltonsillarAutoregulation Breakthrough ZoIntracranial Pressure PathophysiologyIntracranial Pressure PathophyElevated ICP Clinical SymptomsHeadache- Aggravated by bending and stooping. Caused by distortion or irritation of pain sensitive areas in the dural coverings and blood vessels.Vomiting-

9、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 stimulation of the nucleus of vagus nerve.Personality and behavior changes- A depression in motor and thought processes t

10、hat 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. Papilledema- this is usually the result of increased CSF pressure in the optic nerve sheath impeding venous drainage and

11、 axoplasmic flow in optic neurons.Elevated ICP Clinical SymptomsUpwardcerebellumtentoriumCombined AnalysisInterstitial e.ICP TreatmentCushings TriadAutoregulationTotal Volume 1300-1500 ccHerniation TypesElevated ICP Clinical SymptomsCytotoxic dead/dying cellsCombined AnalysisBarbiturate ComaHyperten

12、sion/Increased Pulse PressureTonsillarcerebellumforamen m.Arterial 30% 45ccICP (mm Hg)Uncal uncustentoriumPCAUncal uncustentoriumPCACranial RestrictionPagets disease, craniosynostosisIntracranial Pressure PathophysiologyAutoregulationUpwardcerebellumtentoriumPapilledemaUpwardcerebellumtentoriumPElev

13、ated ICP Clinical SymptomsCranial NeuropathyCN III or VICushings TriadHypertension/Increased Pulse PressureBradycardiaIrregular RespirationElevated ICP Clinical SymptomsElevated ICP Clinical SymptomsElevated ICP Clinical SymptomsICP MeasurementRadiographicNot particularly accurateOther Non-invasiveU

14、nproven: infra-red, laser, TCD (Pulsatility Index)InvasiveLumbar punctureOtherICP MeasurementRadiographicICP MeasurementICP Measurement ICP TreatmentHead of Bed 30 degreesImproves venous drainageLasixDiuretic decreases intravascular volumeMannitol (older agents glycerol, urea)Osmotic diureticDiureti

15、c decreases intravascular volumeOsmotic agent removes free water by osmosisViscosity improves micro-circulation ICP TreatmentHead of Bed 30 ICP TreatmentSedation/AgitationDecrease unnecessarily elevated blood pressure and intravascular volumeIntubation/HyperventilationDecrease pCO2 (25-30 torr), cha

16、nge H+ gradient at blood vessel causing vasoconstriction, leading to decreased intravascular volumeFever controlHyperthermia leads to increased cerebral blood flow and increased blood volume ICP TreatmentSedation/AgitatiICP TreatmentBarbiturate ComaDecrease cerebral metabolic demandHypothermiaDecrea

17、se cerebral metabolic demandHypertonic SalineOsmotic gradientsSurgeryICP TreatmentBarbiturate ComaElevated ICP TreatmentElevated ICP TreatmentElevated ICP TreatmentI USED TO HAVE AN OPEN MIND BUT MY BRAINS KEPT FALLING OUT George CarlinElevated ICP TreatmentI USED THemicraniectomy TrialsDECIMAL - Fr

18、anceDESTINY - GermanyHAMLET - NetherlandsHemicraniectomy TrialsDECIMAL I USED TO HAVE AN OPEN MINDSevere disability or death 12 monthsMass DisplacementElevated ICP Clinical SymptomsCranial NeuropathyI USED TO HAVE AN OPEN MINDHypothermiaICP TreatmentInterstitial e.Hemicraniectomy TrialsSubfalcine ci

19、ngulate g.Subfalcine cingulate g.Papilledema- this is usually the result of increased CSF pressure in the optic nerve sheath impeding venous drainage and axoplasmic flow in optic neurons.ICP (mm Hg)Intracranial Pressure PathophysiologyPapilledemaUpwardcerebellumtentoriumCranial ContentsMass must be

20、displacedDeath 12 monthsLiquid contents are incompressibleICP (mm Hg)Combined AnalysisNIHSS 15MCA strokeWithin 45 hoursI USED TO HAVE AN OPEN MINDComCombined AnalysisSevere disability or death 12 monthsARR 51.2%, p0.0001Death 12 monthsARR 50.3%, p0.0001Combined AnalysisSevere disabiElevated ICP Trea

21、tmentHemicraniectomyElevated ICP Treatment顱內(nèi)高血壓英文精選課件顱內(nèi)高血壓英文精選課件Novel Approaches to ICH/IVH Mass EffectAspiration +/- thrombolysis. This makes intuitive sense. Does it work?Novel Approaches to ICH/IVH MaIntracranial Pressure PathophysiologyMass DisplacementCSF Blood BrainIntracranial Pressure Pathop

22、hyElevated ICP Clinical SymptomsCranial NeuropathyCN III or VICushings TriadHypertension/Increased Pulse PressureBradycardiaIrregular RespirationElevated ICP Clinical SymptomsElevated ICP TreatmentI USED TO HAVE AN OPEN MIND BUT MY BRAINS KEPT FALLING OUT George CarlinElevated ICP TreatmentI USED TC

23、ombined AnalysisSevere disability or death 12 monthsARR 51.2%, p0.0001Death 12 monthsARR 50.3%, p 30 degreesHypothermiaAutoregulationUncal uncustentoriumPCAViscosity improves micro-circulationInterstitial e.Arterial 30% 45ccZone of NormalOsmotic agent removes free water by osmosisOsmotic diureticPap

24、illedemaBUT MY BRAINS KEPT FALLING OUT George CarlinThis is usually the result of hydrocephalus and 4th ventricle dilation causing stimulation of the nucleus of vagus nerve.Diuretic decreases intravascular volumeDoes it work?Monro-Kellie Doctrine (1783/1824)Elevated ICP Clinical SymptomsMonro-Kellie

25、 Doctrine (1783/1824)Cytotoxic dead/dying cellsZone of NormalHypertension/Increased Pulse PressureIntubation/HyperventilationNovel Approaches to ICH/IVH Mass EffectCerebral Perfusion Pressure (mm Hg)Fever controlIntracranial Pressure PathophysiologyCombined AnalysisOsmotic agent removes free water b

26、y osmosisDESTINY - GermanyElevated ICP TreatmentVasogenic altered BBB, capillary breakdown, abscessZone of NormalUncal uncustentoriumPCAElevated ICP Clinical SymptomsViscosity improves micro-circulationHypertonic SalineHAMLET - NetherlandsBlood epidural, subdural, subarachnoid, intracerebral, intrav

27、entricular, intravascularZone of NormalHypertonic SalineElevated ICP TreatmentIntracranial Pressure PathophysiologyViscosity improves micro-circulationHypertension/Increased Pulse PressureOsmotic agent removes free water by osmosisDecrease pCO2 (25-30 torr), change H+ gradient at blood vessel causin

28、g vasoconstriction, leading to decreased intravascular volumeBradycardiaDiuretic decreases intravascular volumeMannitol (older agents glycerol, urea)Cerebral Blood FlowSubarachnoid 50% 75 ccElevated ICP Clinical SymptomsHypertonic SalineCSF 10%Combined AnalysisOsmotic agent removes free water by osm

29、osisICP (mm Hg)CSF 10%Cranial ContentsHydrocephalus, Cysts, HygromaThis makes intuitive sense.Caused by distortion or irritation of pain sensitive areas in the dural coverings and blood vessels.ICP TreatmentDecrease cerebral metabolic demandViscosity improves micro-circulationWithin 45 hoursCN III o

30、r VICytotoxic dead/dying cellsIntracranial Pressure PathophysiologyHemicraniectomy TrialsHerniation TypesDecrease unnecessarily elevated blood pressure and intravascular volumeCranial RestrictionPagets disease, craniosynostosisPapilledemaOsmotic diureticDeath 12 monthsIntracranial Pressure Pathophys

31、iologyElevated ICP TreatmentCytotoxic dead/dying cellsSevere disability or death 12 monthsWithin 45 hours(ml/100 g/min)Osmotic agent removes free water by osmosisDeath 12 monthsOsmotic diureticThis makes intuitive sense.Cranial ContentsPapilledema- this is usually the result of increased CSF pressure in the optic nerve sheath impeding venous drainage and axoplasmic flow in optic neurons.Irregular RespirationUsually occurs with lesions of the posterior fossa.H