Intracranial pressure: measurement and monitoring. CSF pressure as a golden standard. Intraparenchymal pressure. Sensors, drifts, errors and

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1 Intracranial pressure: measurement and monitoring. CSF pressure as a golden standard. Intraparenchymal pressure. Sensors, drifts, errors and monitoring techniques

2 GUILLAUME J, JANNY P. [Continuous intracranial manometry; physiopathologic and clinical significance of the method]. Presse Med Jul 4;59(45):953-5 Lundberg N. Continuous recording and control of ventricular fluid pressure in neurosurgical practice. Acta Psychiat Neurol Scand1960;36(suppl 149):1 193.

3 Monitoring of CSF pressure: instant manometric CSF column measurement is inadequate Owler BK, Fong KC, Czosnyka Z. Importance of ICP monitoring in the investigation of CSF circulation disorders.br J Neurosurg Oct;15(5):439-40

4 Golden standard: ventricular CSF pressure or Lumbar CSF pressure Thanks to Dr. DJ Kim

5 Fluid filled line connected to CSF space (ventricular or lumbar) with external pressure transducer Advantages: 1. Possible re-calibration and zeroing 2. Possible check of patency Disadvantages: 1. Risk of infection 2. Low frequency bandwidth

6 Problems with CSF pressure monitoring through intraventricular catheter Thanks to Dr. K Aquilina

7 Microtransducers- early solutions

8 Thanks to Mr P.Hutchinson

10 Thanks to Ms D. Tangun

12 Example- diameters and setup Thanks to Dr. R.Penn

13 Thanks to Ms. Christele Nardo

14 Thanks to Ms. Christele Nardo

15 Spiegelberg ICP transducer Principle: Transmission of pressure from inside the body to the outside through air. Partially filled air-pouch transmits pressure to the air-column. First published by EJ Marey, Thanks to Dr. A.Spiegelberg

17 Thaks to Mr.K.Aquilina

18 Telemetry early solutions

19 Long term telemetric ICP monitoring Intracranial Pressure vs. Time in Asymptomatic Shunted Patients March 16 March 23 March 30 April 6 April 13 April 20 April 27 May 4 May 11 Time (Days) Thanks to Dr. D.Frim

20 Rotterdam Transfontanelle ICP transducer

21 Cambridge Shunt Evaluation Lab- testing of ICP microtransducers

23 24-hours time drift Comparison of 3 microtransducers (A-Camino, B-Codman, C- Fiberoptic Ventrix)

24 Temperature drift of Camino transducer

25 Static and dynamic accuracy of transducer can be measured in laboratory

26 ICP is related to body posture 20 ICP [mmhg] 0-10 Awake- sitting Asleep- horizontal

27 Normal ICP in horizontal (left) and in sitting up position (right) 15 ICP [mm HG] 0

28 Statistics: 63 non-shunted patients

29 CSF versus intraparenchymal pressure Lumbar [mmhg] Tissue [mmhg]

30 Lumbar [mm Hg] Tissue [mm Hg] Cross spectrum [mm Hg] Transfer Lumbar/Tissue

31 Phase shift between lumbar pulse and parenchymal pulse Lumbar [mm Hg] Tissue [mmhg]

32 What intraparenchymal microsensor really measures Pressure in water- scalar Pressure in brain- tensor

34 Monitoring through EVD versus intraparenchymal probe

35 Thanks to Prof.JD.Pickard Coupling between ICP and Sagittal Sinus Pressure investigated in Idiopathic Intracranial Hypertension A B C D Various forms of focal venous sinus obstruction in the transverse sinuses of 4 patients. Intrinsic filling defects are obvious in the top two radiographs being an arachnoid granulation (A) and a broad based undulating lesion (B). Of the lower two, the radiograph on the left (C) could be a focal stricture or extrinsic compression while the radiograph on the right (D) appears to indicate secondary venous sinus compression or irregularity due to old thrombus.

36 [mm Hg] Pss [mmhg]

37 ICP Pss [mmhg] Pss ICP Relationship between slow waves of Pcsf and Psss (at baseline)

38 Correlation between baseline pressures

39 ICP monitoring artefacts. Tracheal suction ICP mmhg

40 Coughing ICP mmhg

41 Shigekuni Tachibana, Hideo Iida and Kenzoh Yada. Significance of positive Queckenstedt test in patients with syringomyelia associated with Arnold-Chiari malformations Journal of Neurosurgery, January 1992, Vol. 76, No. 1, Pages 67-71

42 Summary Manometric lumbar assessment may be misleading Definition: ICP= CSF pressure in ventricles measured in horizontal position Variations: Intraparenchymal pressure, lumbar CSF pressure, transfontanelle pressure Intraparenchymal transducers measure vector of force not pressure! Advantages: long term stability, low infection risk Sagittal sinus pressure: always stable? ICP depends on body posture and activity Artefacts: mainly dependent on changes in venous pressure

10. Monitoring of pressure-volume compensation- VPR and RAP

10. Monitoring of pressure-volume compensation- VPR and RAP Various shapes of Pressure-Volume curves J.Neurosurg 1975, Vol 42 Volume pressure response is proportional to mean ICP but not always Avezaat