CNS PBL TRIGGER 1

ICP is measured in millimeters of mercury (mmHg) and, at rest, is normally 7

15 mmHg for a supine adult, and becomes negative (averaging 10 mmHg) in
the vertical position.
Normal intracranial pressure
ICP is generally measured in mm Hg to allow for comparison with MAP and to
enable quick calculation of CPP. It is normally 7-15 mm Hg in adults who are
supine, with pressures over 20 mm Hg considered pathological and pressures
over 15 mm Hg considered abnormal.[30]
Note that ICP is positional, with elevation of the head resulting in lower values.
A standing adult generally has an ICP of -10 mm Hg but never less than -15
mm Hg.[31] In supine children, ICP is normally lower, in the range of 15 mm
Hg, with infants having ICP from 5-10 mm Hg and newborns have
subatmospheric pressures regardless of position.[32]
In adults, the choroid plexus and other locations in the CNS produce CSF at a
rate of 20 mL/hour, for a total of 500 mL/day. It is reabsorbed by the arachnoid
granulations into the venous circulation. CSF volume is most commonly
increased by a blockage of absorption due to ventricular obstruction,
occlusion of venous sinuses, or clogging of the arachnoid granulations.

Raised / Increased Intracranial Pressure

Space-occupying lesions: Tumor, abscess, intracranial hemorrhage (epidural

hematoma, subdural hematoma, intraparenchymal hematoma)
CSF flow obstruction (hydrocephalus): Space-occupying lesion that
obstructs normal CSF flow, aqueductal stenosis, Chiari malformation
Cerebral edema: Due to head injury, ischemic stroke with vasogenic edema,
hypoxic or ischemic encephalopathy, postoperative edema
Increase in venous pressure: Due to cerebral venous sinus thrombosis, heart
failure, superior vena cava or jugular vein thrombosis/obstruction
Metabolic disorders: Hypo-osmolality, hyponatremia, uremic encephalopathy,
hepatic encephalopathy
Increased CSF flow production: Choroid plexus tumors (papilloma or
carcinoma)
Idiopathic intracranial hypertension
Pseudo tumor cerebri

How to measure it ???

There are three ways to monitor pressure in the skull (intracranial pressure).
INTRAVENTRICULAR CATHETER
The intraventricular catheter is the most accurate monitoring method.
To insert an intraventricular catheter, a hole is drilled through the skull. The
catheter is inserted through the brain into the lateral ventricle. This area of the
brain contains liquid (cerebrospinal fluid or CSF) that protects the brain and
spinal cord.
The intracranial pressure (ICP) can at the same time as monitoring by draining
fluid out through the catheter.
The catheter may be hard to get into place when the intracranial pressure is
high.
SUBDURAL SCREW
This method is used if monitoring needs to be done right away. A hollow
screw that is inserted through a hole drilled in the skull. It is placed through
the membrane that protects the brain and spinal cord (dura mater). This allows
the sensor to record from inside the subdural space.
EPIDURAL SENSOR
An epidural sensor is inserted between the skull and dural tissue. The epidural
sensor is placed through a hole drilled in the skull. This procedure is less
invasive than other methods, but it cannot remove excess CSF.
Lidocaine or another local anesthetic will be injected at the site where the cut
will be made. You will most likely get a sedative to help you relax.
First the area is shaved and cleansed with antiseptic.
After the area is dry, a surgical cut is made. The skin is pulled back until the
skull is seen.
A drill is then used to cut through the bone.
INDICATIONS

CONTRAINDICATIONS
Placement of an ICP monitor has no absolute contraindications, because it is a
relatively low-risk procedure. However, clinical judgment should be exercised,
especially in patients with a known bleeding disorder. Patients with
thrombocytopenia (platelets count of < 10,000/L), known platelet dysfunction
(inhibition due to antiplatelet agents such as aspirin/clopidogrel or uremic

encephalopathy), prothrombin time greater than 13 seconds, or an

international normalized ratio (INR) greater than 1.3 are at elevated risk for
hemorrhage secondary to placement of an ICP monitor.
ACUTE MENINGITIS
Neisseria meningitidis
(meningococcal meningitidis)
Haemophilus influenza
(serotype B)
Streptoccosus pneumonia
(streptococcal meningitidis)

CHRONIC MENINGITIS
- meningeal inflammation that persists
for more than 4 weeks.
Cryptococcus neoformans
Coccidoides immitis

Neonatal Meningitis
- Meningitis in newborns is almost always a result of infection transmitted by
the mother, either in utero or (more frequently) during passage through the
birth canal

* Other causes : Staphylococcus aureus

The types of bacteria that cause bacterial meningitis vary according to the infected individual's
age group.

In premature babies and newborns up to three months old, common causes are group B
streptococci (subtypes III which normally inhabit the vagina and are mainly a cause during
the first week of life) and bacteria that normally inhabit the digestive tract such
as Escherichia coli (carrying the K1 antigen). Listeria monocytogenes (serotype IVb) may
affect the newborn and occurs in epidemics.

Older children are more commonly affected by Neisseria meningitidis (meningococcus)

and Streptococcus pneumoniae (serotypes 6, 9, 14, 18 and 23) and those under five
byHaemophilus influenzae type B (in countries that do not offer vaccination).[2][4]

In adults, Neisseria meningitidis and Streptococcus pneumoniae together cause 80% of

bacterial meningitis cases. Risk of infection with Listeria monocytogenes is increased in
persons over 50 years old.[4][5] The introduction of pneumococcal vaccine has lowered rates
of pneumococcal meningitis in both children and adults.[13]

RING-ENHANCING LESIONS

Physiology

A. Anatomy of the bloodbrain barrier

It is the barrier between cerebral capillary blood and the CSF. CSF fills the
ventricles and the subarachnoid space.
It consists of the endothelial cells of the cerebral capillaries and the choroid
plexus epithelium.

Prevalence of meningitis