week 9 neuro 634
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Intracranial pressure
1.
Briefly discuss the condition/disorder.
The intracranial space is made up of three components including the brain tissue, cerebrospinal
fluid, and blood supply (Canac et al., 2020). Intracranial pressure (ICP) refers to the pressure within the
skull and is influenced by the cerebrospinal fluid (CSF) pressure. When ICP increases, cerebral arterioles
dilate to reduce cerebral vascular resistance to prevent a further increase in ICP and cerebral blood flow
(Patel et al., 2023). If this initial compensatory mechanism is ineffective, arterial blood pressure goes up.
Both of these responses result in an elevation of cerebral blood volume, leading to an increase in ICP
until cerebral blood flow is impeded. This may lead to more damage to the central nervous system after
an initial injury, as increased pressure within the skull can cause shifting of brain tissue that compresses
or displaces cranial nerves and the brainstem. This compression can also lead to reduced blood flow,
causing ischemia or infarction and resulting in swelling and further harm to the brain tissue. Direct
measurement of intracranial pressure requires invasive monitoring. Intracranial hypertension is diagnosed
when ICP remains elevated above 22 mmHg for more than 5 minutes. Normally, in adults, the ICP is ≤ 15
mmHg. Despite being the pressure within the skull, ICP is directly linked to cerebrospinal fluid pressure
and is influenced by the cardiac cycle. Maintaining normal ICP is crucial for proper brain function.
Conditions such as hydrocephalus, intracranial infections, intracerebral hemorrhages, traumatic brain
injury, and brain tumors can raise ICP levels. If not effectively managed or left untreated, high ICP can
lead to cerebral hypoperfusion, herniation, increased edema and death.
2.
Describe the symptoms and physical exam findings associated with the condition/disorder.
Clinical indications of elevated ICP may encompass nausea and vomiting, headaches, weakness,
blurred vision, or alterations in cognitive function such as disorientation, reduced cognitive capacity,
unconsciousness, or coma (Patel et al., 2023). Some exam findings may vary depending on the cause of
ICP. Unequal pupil dilation, optic disc swelling on fundoscopic examination, abnormal posturing, and
paralysis may be some possible indications on physical exam. Severe increases in ICP can also lead to
the development of Cushing's triad, characterized by high blood pressure, slow heart rate, and abnormal
breathing patterns as a late indication.
3.
Identify appropriate laboratory, imaging, and other diagnostic/screening tools that apply to the
disorder and explain how they will help you with your diagnosis.
It is important to conduct imaging studies to understand what is the cause of the increased ICP.
However, The gold standard monitoring technique for ICP is highly invasive, with an extraventricular drain
(EVD) being the preferred method and an intraparenchymal monitor (IPM) being another regarded
method (Canac et al., 2020). Inserting an EVD involves the placement of a catheter through the skull into
one of the brain's ventricles, typically the lateral ventricle. This catheter is then linked to an external
drainage system that includes a pressure transducer for monitoring pressure levels and allows
cerebrospinal fluid removal when required. An IPM also includes the placement of monitoring probes
through a catheter into the brain, but is slightly less invasive than an EVD and involves reduced risk as it
is on the outside of the parenchyma. There are three types of these sensors including fiber optic, strain
gauge, and pneumatic sensors. In comparison to EVDs, IPMs have been discovered to provide a similar
level of accuracy. Unlike EVDs, however, IPMs do not offer the capability for recalibration after placement,
which is a key advantage that sets EVDs apart as they can be recalibrated at any point in time.
Lumbar puncture (LP) may also be utilized for the measurement of ICP. In cases without
obstruction, LP pressure has been found to closely correlate with ventricular pressure. However, this
procedure is only used when other methods are not available due to its associated risks and its inability to
provide continuous monitoring. CT and MRI can also assist in the assessment, but these imaging
methods are mainly capable of assessing abnormalities that may lead to increased intracranial pressure,
such as hemorrhages and tumors, rather than directly measuring ICP. The Glasgow Coma Scale is a
screening tool that is used to assess for the level of consciousness in patients with suspected increased
intracranial pressure. There are numerous non-invasive methods for monitoring ICP that are being
continuously studied, such as transcranial doppler ultrasonography and near-infrared spectroscopy, but
they are generally not deemed as precise or dependable as the invasive approaches.
4.
List two other conditions that could cause a similar presentation (differential diagnoses) and
explain how you would "rule out" those differentials.
Migraine headaches can be debilitating, causing severe pain and disrupting daily activities. They
may present with similar symptoms as increased ICP, including nausea and vomiting, headaches, and
blurred vision. To rule out migraines, a comprehensive assessment of the patient's medical history with a
specific focus on headache characteristics and response to treatment is essential. Understanding if there
is a family history, if auras are present, and identifying if there are triggers or patterns associated with the
headaches can help differentiate migraines from other causes (Eigenbrodt et al, 2021). Additionally,
neurological exams and checking for PERRLA and papilledema may help in determining a diagnosis, as
they can indicate elevated ICP but are not commonly found in migraine headaches. Imaging studies
including CT can be used to rule out secondary causes of headaches if suspected, such as tumors or
hemorrhages. Assessing the patient's GCS can also provide valuable information about their level of
consciousness and help in ruling out increased ICP as the cause of the headache.
Another differential diagnosis that may need to be considered for increased intracranial pressure
is hypoglycemia. Low plasma glucose levels impair brain function and can result in symptoms that mimic
increased intracranial pressure, such as confusion, altered consciousness, and seizures (Nakhleh &
Shehadeh, 2021). Headaches may also be present in some cases, along with blurred vision. In order to
rule out the cause of symptoms, checking blood glucose levels with a fingerstick or venous blood sample
is necessary. Unlike increased ICP, symptoms of hypoglycemia will often quickly resolve once glucose is
administered and blood sugar levels return to normal.
References
Canac, N., Jalaleddini, K., Thorpe, S.G., Thibeault, C.M. & Hamilton, R. (2020)
.
Review:
pathophysiology of intracranial hypertension and noninvasive intracranial pressure
monitoring.
Fluids and Barriers of the CNS, 17
(40).
https://doi.org/10.1186/s12987-020-00201-8
Eigenbrodt, A. K., Ashina, H., Khan, S., Diener, C., Mitsikostas, D. D., Sinclair, A. J.,
Pozo-Rosich, P., Martelletti, P., Ducros, A., Lantéri-Minet, M., Braschinsky, M., Daniel, O.,
Özge, A., Mammadbayli, A., Arons, M., Skorobogatykh, K., Romanenko, V., Terwindt, G.
M., Paemeleire, K., . . . Ashina, M. (2021). Diagnosis and management of migraine in ten
steps.
Nature Reviews. Neurology
,
17
(8), 501-514.
https://doi.org/10.1038/s41582-021-00509-5
Nakhleh, A., & Shehadeh, N. (2021). Hypoglycemia in diabetes: An update on
pathophysiology, treatment, and prevention.
World Journal of Diabetes
,
12
(12),
2036-2049. https://doi.org/10.4239/wjd.v12.i12.2036
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