颅内高血压英文-课件

IntracranialPressurePhysiologyMonro-KellieDoctrine(1783/1824)1. Rigidcontainer2. Liquidcontentsareincompressible3. MassmustbedisplacedIntracranialPressurePhysiologyCranialContentsTotalVolume1300-1500ccBrain~80%graymatter/whitematterCSF~10% Intraventricular50%75cc Subarachnoid50%75ccBlood~10% Arterial30%45cc Venous70%105ccIntracranialPressurePathophysiologyBlood–epidural,subdural,subarachnoid,intracerebral,intraventricular,intravascularTumorAbscess/InfectionForeignObjectsAir–pneumocephalusCranialRestriction–Paget’sdisease,craniosynostosisHydrocephalus,Cysts,HygromaEdemaInterstitial–e.g.CNSlymphsystem,brainasaspongeCytotoxic–dead/dyingcellsVasogenic–alteredBBB,capillarybreakdown,abscessIntracranialPressurePathophysiologyMassDisplacementCSFBloodBrainICP/CPP

150125100755025002550CerebralPerfusionPressure(mmHg))CerebralBloodFlow(ml/100g/min)ZoneofNormalAutoregulationMaximumConstrictionMaximumDilatationPassiveCollapse02550ICP(mmHg)VasodilatoryCascadeZoneAutoregulationBreakthroughZoneStephanA.Mayer,MDIntracranialPressurePhysiologyIntracranialPressurePathophysiologyHerniationTypes Structure Barrier VesselSubfalcine cingulateg. falx ACAUncal uncus tentorium PCATonsillar cerebellum foramenm.vert/bUpward cerebellum tentoriumTranscalvarial cortex skull surfaceIntracranialPressurePathophysiologyHerniationTypesSubfalcineUncaltonsillarIntracranialPressurePathophysiologyElevatedICPClinicalSymptomsHeadache-Aggravatedbybendingandstooping.Causedbydistortionorirritationofpainsensitiveareasintheduralcoveringsandbloodvessels.Vomiting-Causedbycompressionorischemiaofbrainstem.Usuallyoccurswithlesionsoftheposteriorfossa.Thisisusuallytheresultofhydrocephalusand4thventricledilationcausingstimulationofthenucleusofvagusnerve.Personalityandbehaviorchanges-

Adepressioninmotorandthoughtprocessesthatcanleadtosomnolence,anddecreasedlevelofconsciousnessandcoma.Causedbycompressiononthereticularsubstanceofupperbrainstemandthalamuscausesthisphenomenon.Papilledema-thisisusuallytheresultofincreasedCSFpressureintheopticnervesheathimpedingvenousdrainageandaxoplasmicflowinopticneurons.PapilledemaDeath@12monthsPapilledemaElevatedICPClinicalSymptomsIntracranialPressurePathophysiologyCerebralPerfusionPressure(mmHg))Severedisabilityordeath@12monthsIntracranialPressurePhysiologyBUTMYBRAINSKEPTFALLINGOUTGeorgeCarlinHemicraniectomyCausedbycompressiononthereticularsubstanceofupperbrainstemandthalamuscausesthisphenomenon.MassDisplacementElevatedICPClinicalSymptomsSubarachnoid50%75ccTotalVolume1300-1500ccCSF~10%AutoregulationThisisusuallytheresultofhydrocephalusand4thventricledilationcausingstimulationofthenucleusofvagusnerve.Interstitial–e.HypertonicSaline(ml/100g/min)ElevatedICPClinicalSymptomsCranialNeuropathyCNIIIorVICushing’sTriadHypertension/IncreasedPulsePressureBradycardiaIrregularRespirationElevatedICPClinicalSymptomsICPMeasurementRadiographicNotparticularlyaccurateOtherNon-invasiveUnproven:infra-red,laser,TCD(PulsatilityIndex)InvasiveLumbarpunctureOtherICPMeasurement

ICPTreatmentHeadofBed>30degreesImprovesvenousdrainageLasixDiuretic–decreasesintravascularvolumeMannitol(olderagentsglycerol,urea)OsmoticdiureticDiuretic–decreasesintravascularvolumeOsmoticagent–removesfreewaterbyosmosisViscosity–improvesmicro-circulation

ICPTreatmentSedation/AgitationDecreaseunnecessarilyelevatedbloodpressureandintravascularvolumeIntubation/HyperventilationDecreasepCO2(25-30torr),changeH+gradientatbloodvesselcausingvasoconstriction,leadingtodecreasedintravascularvolumeFevercontrolHyperthermialeadstoincreasedcerebralbloodflowandincreasedbloodvolumeICPTreatmentBarbiturateComaDecreasecerebralmetabolicdemandHypothermiaDecreasecerebralmetabolicdemandHypertonicSalineOsmoticgradientsSurgeryElevatedICPTreatmentElevatedICPTreatmentIUSEDTOHAVEANOPENMINDBUTMYBRAINSKEPTFALLINGOUTGeorgeCarlinHemicraniectomyTrialsDECIMAL-FranceDESTINY-GermanyHAMLET-NetherlandsCombinedAnalysisNIHSS>15MCAstrokeWithin45hoursIntracranialPressurePathophysiologyForeignObjectsPapilledemaHypertension/IncreasedPulsePressureElevatedICPClinicalSymptomsInterstitial–e.Thisisusuallytheresultofhydrocephalusand4thventricledilationcausingstimulationofthenucleusofvagusnerve.Air–pneumocephalusElevatedICPTreatmentElevatedICPClinicalSymptomsMassmustbedisplacedLiquidcontentsareincompressibleViscosity–improvesmicro-circulationHeadofBed>30degreesMassDisplacementDECIMAL-FranceIntracranialPressurePhysiology(ml/100g/min)IUSEDTOHAVEANOPENMINDElevatedICPClinicalSymptomsCombinedAnalysisSeveredisabilityordeath@12monthsARR51.2%,p<0.0001Death@12monthsARR50.3%,p<0.0001ElevatedICPTreatmentHemicraniectomyNovelApproachestoICH/IVHMassEffectAspiration+/-thrombolysis.Thismakesintuitivesense.Doesitwork?IntracranialPressurePathophysiologyMassDisplacementCSFBloodBrainElevatedICPClinicalSymptomsCranialNeuropathyCNIIIorVICushing’sTriadHypertension/IncreasedPulsePressureBradycardiaIrregularRespirationElevatedICPTreatmentIUSEDTOHAVEANOPENMINDBUTMYBRAINSKEPTFALLINGOUTGeorgeCarlinCombinedAnalysisSeveredisabilityordeath@12monthsARR51.2%,p<0.0001Death@12monthsARR50.3%,p<0.0001ElevatedICPTreatmentHemicraniectomyElevatedICPTreatmentElevatedICPTreatmentDECIMAL-FranceAir–pneumocephalus(ml/100g/min)Severedisabilityordeath@12monthsBlood–epidural,subdural,subarachnoid,intracerebral,intraventricular,intravascularDeath@12monthsBlood–epidural,subdural,subarachnoid,intracerebral,intraventricular,intravascularDoesitwork?ElevatedICPTreatmentBradycardiaElevatedICPClinicalSymptomsHeadofBed>30degreesIntracranialPressurePathophysiologyCNIIIorVIIUSEDTOHAVEANOPENMINDIntracranialPressurePathophysiologyDecreasepCO2(25-30torr),changeH+gradientatbloodvesselcausingvasoconstriction,leadingtodecreasedintravascularvolumeUpward cerebellum tentoriumDECIMAL-FranceUsuallyoccurswithlesionsoftheposteriorfossa.CSF~10%Air–pneumocephalusIntracranialPressurePhysiologyViscosity–improvesmicro-circulation(ml/100g/min)DecreasepCO2(25-30torr),changeH+gradientatbloodvesselcausingvasoconstriction,leadingtodecreasedintravascularvolumeIrregularRespirationArterial30%45ccBUTMYBRAINSKEPTFALLINGOUTGeorgeCarlinIntraventricular50%75ccBlood~10%ElevatedICPTreatmentViscosity–improvesmicro-circulationViscosity–improvesmicro-circulationBUTMYBRAINSKEPTFALLINGOUTGeorgeCarlinAbscess/InfectionInterstitial–e.RigidcontainerSedation/AgitationIntracranialPressurePathophysiologyCausedbycompressiononthereticularsubstanceofupperbrainstemandthalamuscausesthisphenomenon.Viscosity–improvesmicro-circulationBradycardiaCerebralPerfusionPressure(mmHg))IntracranialPressurePathophysiologyArterial30%45cc(ml/100g/min)IntracranialPressurePathophysiologyBlood–epidural,subdural,subarachnoid,intracerebral,intraventricular,intravascularCNIIIorVIBUTMYBRAINSKEPTFALLINGOUTGeorgeCarlinElevatedICPTreatmentIntracranialPressurePhysiologyIntracranialPressurePathophysiologyDoesitwork?MassDisplacementViscosity–improvesmicro-circulationHemicraniectomyMannitol(olderagentsglycerol,urea)BUTMYBRAINSKEPTFALLINGOUTGeorgeCarlinIUSEDTOHAVEANOPENMINDPersonalityandbehaviorchanges-

Adepressioninmotorandthoughtprocessesthatcanleadtosomnolence,anddecreasedlevelofconsciousnessandcoma.CranialNeuropathyICPTreatment(ml/100g/min)CNIIIorVICombinedAnalysisBlood–epidural,subdural,subarachnoid,intracerebral,intraventricular,intravascularIntracranialPressurePathophysiologyBlood~10%Sedation/AgitationElevatedICPClinicalSymptomsOsmoticgradient