Raised ICP

Acute Care

Why is an increased ICP an emergency

Pathophysiology

The contents of our skull and dura can be divided into three main compartments: brain parenchyma (which occupies a volume of approximately 1.4 L), spinal fluid (52-160 mL), and blood (150 mL). An increase in any of these three compartments, as per the Monro-Kellie hypothesis, will occur at the expense of the remaining two. In addition, intracranial compliance has been noted to decrease with rising pressure, thus causing further compromise in cerebral perfusion. The normal range of ICP has been reported to be 5 to 15 mm Hg.

*Bethesda Handbook of Oncology

Causes

Etiology

In patients with cancer, volume changes in brain parenchyma can be the result of:

primary or secondary brain tumors +/− intratumoral hemorrhage
vasogenic (peritumoral) or cytotoxic (in the setting of cytotoxic chemotherapy) edema
extra-axial mass lesions (dural tumors, infection, or hemorrhage)
indirect neurologic complications.

Brain metastases are, in fact, the most common cause of increased ICP in this population. Lung cancer and melanoma, specifically, are most commonly associated with central nervous system (CNS) metastasis.

An imbalance between cerebral spinal fluid (CSF) production and reabsorption may also contribute to increased ICP:

subependymal giant cell astrocytoma
lymphoma
choroid plexus papilloma
ependymoma
meningioma

*Bethesda Handbook of Oncology

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Last Update: August 19, 2024

Spinal Cord Compression

Spinal cord compression (SCC) is a true oncologic emergency as delays in diagnosis can cause severe, irreversible neurologic compromise, decline in functional status, and impaired quality of life. SCC affects roughly 3% to 5% of all patients with cancer. The majority of cases result from spine metastases with extension into the epidural space. It is the second most frequent neurologic complication of cancer after brain metastases. The median overall survival of patients with SCC ranges from 3 to 16 months and most die of systemic tumor progression.

August 20, 2024
4:39 am

Raised ICP

The contents of our skull and dura can be divided into three main compartments: brain parenchyma (which occupies a volume of approximately 1.4 L), spinal fluid (52-160 mL), and blood (150 mL). An increase in any of these three compartments, as per the Monro-Kellie hypothesis, will occur at the expense of the remaining two. In addition, intracranial compliance has been noted to decrease with rising pressure, thus causing further compromise in cerebral perfusion. The normal range of ICP has been reported to be 5 to 15 mm Hg.

August 19, 2024
6:10 am

SVC Syndrome

Superior vena cava (SVC) syndrome occurs when blood flow through the SVC becomes obstructed due to external compression or internal occlusion by tumor invasion, fibrosis, or an intraluminal thrombus. This subsequently impairs venous drainage from the head, neck, upper extremities, and thorax. Decreased venous return to the heart, in turn, causes decreased cardiac output, increased venous congestion, and edema.

August 19, 2024
5:29 am

Chest Tubes

In this episode of our emergency and critical care procedures series we take a look at how to insert a tube thoracostomy. In this real case Dr Chris Moseley and Dr Andy Steval talk you through how to do this critical procedure in a real patient with a haemothorax.