ICP

Waveform
Analysis
Joanne Ball RN
Intensive Care Unit
Westmead Hospital

Why look at ICP waveform

analysis?
provides information about intracranial dynamics that can help

identify individuals
who have decreased adaptive capacity and are

at risk for increases in ICP

and decreases in CPP,

which may contribute to secondary brain injury

and have a negative impact on neurologic outcome.
C.J Kirkness et. al, 2000, 32;5, 271

ATLS Course Manual, American College of Surgeons, 1997

Monro-Kellie doctrine
increase in one component
(brain swelling)
or
addition of new component
(haematoma)
displaces another component
skull
closed box, fixed volume

contents
blood, brain and CSF
non-compressible fluids

ATLS Course Manual, American College of Surgeons, 1997

compliance reflects the

ability of the intracranial
system to compensate for
increases in volume
without subsequent
increases in ICP. When
compliance is decreased
even small increases in
intracranial volume
result in large increases
in ICP
C.J Kirkness et. al, 2000, 32,5 271

ATLS Course Manual, American College of Surgeons, 1997

Methods of
ICP measurement
Technology
external strain gauge
catheter tip (internal)
strain gauge
fibre-optic
Location
Ventricular (EVD/IVC)
Intraparenchymal
Subarachnoid
Subdural/Extradural
External Fontanelle

Normal ICP
It is difficult to establish a universal
normal value for ICP as it depends on
age, body posture and clinical
conditions.

The ICP Waveform

P1 (percussion wave)
sharp peak and a fairly
constant amplitude.

P2 (tidal wave)
ends on the dicrotic
notch.

P3 (dicrotic wave)
3 peaks
relation to the arterial &
venous pulse waveforms.

follows the dicrotic

notch.
Influenced by

North B, in Head Injury Ed. Reilly & Bullock, 1997

Condition that
ICP

Waveform changes

Mass lesion

Increase waveform amplitude (P2)

CSF volume

Increase/ decrease waveform amplitude

Little change in waveform components

BP (hypertension)

Increase waveform amplitude (P1)

venous volume

Increase waveform amplitude (P2)

(rounding of ICP waveform due to
increase in later waveform components)

Hypoventilation
Venous compression

adapted from C.J Kirkness et. al, 2000, 32;5, 273.

Interpretation of ICP

Elevation of P2
suggests poor compliance
predictive of poor outcome

C.J Kirkness et. al, 2000, 32;5, 273.

The ICP Waveform

related to
cardiac cycle : within individual waves
respiratory cycle : between consecutive waves
North B, in Head Injury Ed. Reilly & Bullock, 1997

ICP wavetrends : A waves

Waves that plateau as high as 30-70mmhg and remain elevated for

as long as 20 minutes indicate that CPP is being significantly
compromised.

Muller et al. Pan Arab Journal of Neurosurgery 2000 4;2.

Summary
Visual assessment of the ICP waveform
can provide information about decreased
intracranial compliance and altered
intracranial dynamics :

Increased amplitude
Elevated P2 and
Rounding of the waveform
A or plateau waves

References
Kirkness CJ et al. (2000)
Intracranial Pressure Waveform Analysis: Clinical and Research
Impications.
Journal of Neuroscience Nursing 32:5

Czosnyka M & Pickard JD (2004)

Monitoring and Interpretation of Intracranial Pressure.
Journal of Neurology Neurosurgery & Psychiatry 75:813-821

North B (1997)
Intracranial Pressure Monitoring
in Reilly & Bullock (eds) Head Injury, Chapman & Hall.

Muller et al. (2000)

Intracranial Pressure (ICP) and Cerebrospinal Fluid (CSF)
Dynamics
Pan Arab Journal of Neurosurgery 2000 4;2.