Intracranial hypertension: what to do? (is that bad ?)

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In our skull, there is a pressure called intracranial pressure. Sometimes this pressure increases above 15 mmHg and it is called intracranial hypertension (ICHT or HIC). Several factors can be the cause. It is a disorder that requires rapid treatment, especially if the pressure is substantial. In this article, find out what to do with intracranial hypertension.

Understanding intracranial hypertension

Definition

Intracranial hypertension is a syndrome defined by the increase, in a lasting way, of the intracranial pressure beyond its normal value which is 15 mmHg. It is accompanied by an increase in volume either of the cerebral parenchyma or of the cerebrospinal fluid, or of the cerebral blood volume.

Pathophysiology

To better understand this definition, let us recall that interior of our skull, there are 3 entities:

  • the brain which occupies 80% of the intracranial volume;
  • the blood system (10%);
  • the cerebrospinal fluid (or CSF) occupying the remaining 10%.

The distribution of these volumes must be maintained challenge.

Intracranial pressure (ICP) results from the pressure balance between these three entities. Thus, the variation of the ICP is induced by the changes at the level of these 3 entities: the changes at the level of the brain, the fluctuations of the quantities due to the secretion and the resorption of the CSF and the variations of the blood circulation.

From a lower variation de volume, the body carries out a mechanism compensator for bring back la pressure intracranial to the normal.

This can be explained by the fact that the parenchyma cerebral can provide some of its intra or extracellular waters to buffer the variation in blood volume or CSF volume. On the other hand, the latter can also lend volume by playing on the process of secretion and resorption. the système vascular, meanwhile, can also restore ICP balance by yielding some arterial or venous blood volume.

It is also thanks to this compensation mechanism that the PIC is generally maintained to his normal value, that is to say between 8 and 15 mmHg in adults. This is possible even after the phenomena that generate increases passagères such the cough which could increase the ICP beyond 40 mmHg.

However, there are factors that cause this compensation mechanism to weaken. This is especially the case if the causal factor sets in very quickly and considerably upsets the volumes. Thus, the increase in intracranial pressure will last longer. This then explains the mechanism of HTIC.

 

 

What can be the causes of HTIC?

We categorize the main etiologies of ICHT in 3 types:

Expansive etiologies

They can hamper le mechanism de compensation by a cerebral hernia.

The main factors are:

  • the you die and metastases especially those who have rather quick installation (like brain metastases with perilesional edema)
  • the trauma cranioencephalic with hematoma, cerebral edema…
  • the causes vascular : intra-parenchymal hematomas, thalamic hematomas, arterial infarctions, subarachnoid hemorrhages, which disturb the CSF circular.
  • The brain infections and its membranes : cerebral abscess (due to the perilesional edema which disturbs the ICP), subdural empyema…
  • the CSF circulation disorders (hydrocephalus, malformation ou obstruction

Lesional factors

  • cerebral venous thrombophlebitis
  • causes of venous obstruction or stenosis
  • chronic meningitis, etc.

Benign and secondary ICH 

  • HIC secondary to medication (stop taking corticosteroids, growth hormones, antibiotics such as tetracycline, excess vitamin A, etc.).
  • HIC secondary to a pathology  such as kidney failure, sleep disorders...
  • swelling of brain tissue following a radiotherapy.
  • Idiopathic ICH where the cause remains unknown. But it is extremely rare and is only encountered in 1 individual out of 100, mainly in women and individuals in overweight. Accumulation full mass gain greasy thorax peut hamper la circulation Sanguine between head and thorax and promote a intracranial hypertension.

How does intracranial hypertension manifest?

HTIC is revealed by symptoms following.

  • Personalized headache with characteristics unusual : they appear on matin or second part of the night. The patient will feel ill either way diffuse, or at the level occipital, either at the level of the region front of the head. The pain will be keep on going, pulsating and type of tightness. She will exaggerated by position lying down, the effort, cough and defecation. Resistant Asked analgesics ou painkillers usual, they go get worse gradually.
  • Personalized vomiting en jects which temporarily relieve headaches. They are triggered by certain head positions and have nothing to do with meals.
  • Personalized unrest psychic as the confusion and unrest psychiatric (irritability and character change).
  • Personalized unrest full vigilance, namely the drowsiness, obsessiveness, even the coma.
  • Personalized unrest visuals manifesting itself by a decrease full capacity visual or by a diplopia (double vision). 
  • Personalized tinnitus.

Particularly, in newborns or infants, an increase in head circumference is noticeable, because their cranial box is still extensible. There will also be a bulging of the fontanelles, a sunset gaze and a dilation of the veins of the scalp.

In older children, we will especially notice a difficulty at school level, optic atrophies and behavioral disorders.

Over time, ICHT will result in cerebral engagement, which results in the following signs.

  • Aggravation of vigilance disorders.
  • Vital signs disorders such as heart rate, blood pressure or respiratory rate.
  • In case of engagement at the level of the temporal region: there will be a coma, pupillary abnormalities (unilateral mydriasis with ptosis, abolition of the photomotor reflex), a ipsilateral hemiplegia and later a decerebrate rigidity
  • If there is involvement in the tonsillar region, it is expected that a occipital headache. It radiates to the neck, giving nuqualgia and neck stiffness of the type torticollis with a stiff attitude. In addition, yawning, hiccups, vegetative disorders will be seen. Later, some crises tonic and abrupt lower limbs and head, with obstinacy, will appear, hence the attitude called opisthotonos

What about diagnosing hypertension inside the skull?

Le diagnostic is posed thanks to results de l 'exam clinical.

First, you have to make a examination well conducted, making it possible to detect all the symptoms in favor of the HTIC.

Then, a thorough and methodical physical examination must be carried out. It consists of making neurological examinations looking for signs according to the causal pathology and the type of cerebral involvement. A fundus examination is not to be neglected, as it will reveal ICHH through ocular involvement. We will discover there:

  • un edema papillary bilateral which will result in a protruding papilla with soft edges;
  • a atrophy cover which is evoked in front of pale, discolored, bilateral ocular papillae.

The exams paraclinical are necessary for confirm the presence of hypertension. We will thus discover the causes and sequelae at the level of the brain.

Le scanner cerebral is indicated in the first intention. But for more precision in the diagnosis, MRI (magnetic resonance imaging) and theangioMRI can be recommended. Other exams like radiography of the skull have little of interest.

Attention ! Lumbar puncture is contraindicated if intracranial hypertension is suspected. This must be eliminated by carrying out a brain scan. 

ICHT treatments

The HTIC is a therapeutic urgency. It must be taken care of quickly and in a specialized service.

Symptomatic treatments

 These treatments are necessary and consist of:

  • put the head and trunk in the correct position, 15 to 30 degrees, in relation to the body;
  • ensure optimal ventilation, either using mask oxygenation or orotracheal intubation for mechanical ventilation;
  • give antipyretics such as paracetamol in case of fever, because hyperthermia will aggravate ICHH;
  • infuse only 1000 ml per day of isotonic saline, to maintain normal blood volume while avoiding water and sodium loss;
  • administer anti-oedematous treatments, as ICHT causes cerebral oedema. In particular, hypertonic solutions such as mannitol are prescribed, which will be replaced by glycerol after 48 hours. Corticosteroids (solumedrol, methylprednisolone, etc.) are also given, especially in the event of a tumor or cerebral abscess, diuretics (Diamox, Furosemide, etc.) and barbiturates.

Etiological treatments

Symptomatic treatments are not enough. Etiological treatments must also be carried out, such as:

  • the antibiotics in the event of an infectious cause such as meningitis;
  • the antihypertensives in the event of an acute hypertensive crisis;
  • the anti coagulants in case of cerebral thrombophlebitis;
  • the use of the surgery for hematoma evacuation, external ventricular shunt (in case of hydrocephalus), or even internal ventricular shunt, and lumpectomy. 

All these treatments must be associated with clinical and paraclinical monitoring of the patient by the attending physician.

References

https://medicalforum.ch/fr/detail/doi/fms.2019.08275

https://www.msdmanuals.com/fr/accueil/troubles-du-cerveau, — de-la-moelle-%C3%A9pini%C3%A8re-et-des-nerfs/c%C3%A9phal%C3%A9es/hypertension-intracr%C3%A2nienne-idiopathique

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