Intracranial hypertension

Incidence

The degree of intracranial pressure

Causes and Risk Factors

Symptoms of high intracranial pressure

Diagnostics

Treatment of intracranial hypertension

Complications

Prognosis and prevention

Synonyms: intracranial hypertension, cerebrospinal fluid-hypertensive syndrome, cerebrospinal fluid hypertension syndrome, intracranial hypertension, intracranial pressure, ICP.

ICD-10 Code: G93.2.

Intracranial hypertension – increased pressure of cerebrospinal fluid inside the skull.

The leading symptom is intense headaches in the fronto-parietal region and a feeling of pressure on the eyeballs.

The therapy is based on the use of diuretic drugs designed to reduce pressure due to the output fluid.

Intracranial hypertension is not an independent disease, it is a syndrome that accompanies a number of diseases / injuries of the skull and brain. Separately allocated primary or idiopathic intracranial hypertension, the causes of which are not precisely established. This pathology is made into the diagnosis after excluding other possible factors of increasing intracranial pressure.

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Intracranial pressure considers the difference between pressure in the skull and atmospheric, that is, this term determines the force with which the intracranial fluid pressure on the brain. Normal indicators of this difference are within 5-15 mm Hg. pillar. With increasing intracranial pressure talk about   intracranial or intracranial hypertension.  

In addition to the cranial box, the brain is protected from mechanical influences by a liquid medium – cerebrospinal fluid or cerebral (cerebrospinal) fluid, which is located in the subarachnoid, epidural spaces (cavities between the meninges) and in the cerebral ventricles (cavities located in the brain tissues). The brain, cerebrospinal fluid and intravascular blood are in dynamic equilibrium. When the pressure level of one of the components changes, the pressure in the others is transformed, which is ensured by the properties of the blood and brain fluid (supporting acid-base balance) and the elasticity of the walls of blood vessels and brain tissue. When exposed to certain causes, the regulation of intracranial pressure is disrupted, which leads to the development of liquor hypertension.

Incidence

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The prevalence of pathology ranges from 1-3 cases per 100,000 population among women aged 15-45 years.   In adults, the most common cause of increased intracranial pressure is a head injury. It is noted that men suffer from this pathology less often, the ratio is 4-15 women to 1 man.

Liquorous hypertension syndrome is often exposed to newborns ( hydrocephalus ) and infants (intrauterine hypoxia,   birth asphyxia ).

The degree of intracranial pressure

According to the severity of neurological signs and indicators of intracranial pressure, there are:

  • weak (from 16 to 20 mm of mercury.);
  • moderate (from 21 to 30);
  • pronounced (from 31 to 40);
  • extremely pronounced (over 41 mm Hg. Art.).

Due to the occurrence of intracranial hypertension, it is divided into

  • primary (idiopathic),
  • secondary

By the speed of occurrence of pathology can be

  • acute, when an increase in intracranial pressure develops rapidly (infection of the brain, trauma, acute circulatory disorders),
  • chronic – intracranial pressure increases gradually with the growth of a brain tumor or due to residual effects after trauma, surgery, stroke.

Causes and Risk Factors

Increased intracranial pressure contributes to an increase in the volume of any structure that is in the skull (vessels, brain tissue, CSF depot and cerebrospinal fluid itself). As a result, there is a compression of the brain, which leads to a breakdown of metabolism in its cells, a shift in brain structures and impaired vital functions (respiratory, cardiac) due to compression of the brain stem, which contains the respiratory and cardiovascular centers.

In this regard, all the triggers leading to intracranial hypertension are divided into 4 groups:

Vascular pathology

Conditions causing excessive blood filling of the brain:

  • fever (hyperthermia),
  • hypercapnia (excess CO, for example, in violation of pulmonary ventilation, poisoning with drugs, alcohol, poisonous substances).

States that violate the outflow of blood from the brain:

  • dyscirculatory encephalopathy,
  • cervical osteochondrosis.

Swelling of the brain or its membranes

It can be diffuse (widespread) and local (local).

Observed under the following conditions:

  • bruises brain,
  • ischemic stroke (against hypoxia),
  • infectious diseases ( encephalitis , arachnoiditis,   meningitis )
  • severe hypoxia
  • hepatic encephalopathy.

Volumetric education in the skull

  • Brain tumor (primary or metastatic),
  • Cyst, including parasitic genesis (echinococcosis),
  • Cerebral aneurysm,
  • Abscess of the brain.

Liquorodynamic disorders

May be due to excessive production of liquor, a violation of its absorption or disorders of its circulation (hydrocephalus).

The factors contributing to the occurrence of primary cerebrospinal hypertension are not well understood. Most often this pathology is diagnosed in women and is caused by weight gain. Also, intracranial hypertension is observed in adolescent girls with overweight, in the case of venous sinus thrombosis due to hemorrhagic diathesis, when taking vitamin A in higher doses, treatment with tetracycline, penicillins or after discontinuation of glucocorticoids, with hypo- and hyperthyroidism, pregnancy, cycle disorders.

Risk factors

According to foreign data, the main risk group is obese people with a BMI of over 30.

The risk of developing intracranial hypertension increases with a recent intensive increase in weight of 5–15%, even if the BMI is below 30.  

Symptoms of high intracranial pressure

The leading symptom of intracranial hypertension is headache. With an acute increase in intracranial pressure, the pain is intense and rapidly increasing, in the case of chronic – the pain periodically increases or is constant. Pain in the fronto-parietal areas is localized, the symmetry of the pain and the accompanying feeling of pressure on the eyeballs are characteristic. Some patients speak as a bursting pain or pressing on the inside of the eyes. Often headache is accompanied by nausea and soreness when moving eyes. If intracranial pressure has increased significantly, vomiting occurs at the height of the headache.

In the case of acute cerebrospinal fluid hypertension, disorders of consciousness quickly increase, until a person falls into a coma and seizures appear. In chronic intracranial hypertension, the patient’s general condition deteriorates gradually: irritability appears, sleep is disturbed (sleeplessness at night, sleepiness during the day), increased mental and physical fatigue, meteosensitivity (deterioration of well-being when the atmospheric pressure changes).

Also marked disorders of the functioning of the autonomic nervous system, manifested by irregular blood pressure, palpitations, increased sweating. Chronic intracranial hypertension may be accompanied by liquor-hypertensive crises, which provokes a sharp rise in intracranial pressure.

Clinically, a hypertensive crisis is manifested by an intense headache with nausea and vomiting, in some cases short-term fainting. Also, when intracranial hypertension is observed symptoms of visual impairment: blurred vision, diplopia (doubling), reduced visual acuity.

The severity of clinical manifestations is determined by the nature of the underlying disease and the rate of increase in intracranial pressure. With chronic cerebrospinal fluid hypertension, the symptoms increase gradually (headache first worries only in the morning, slow deterioration of vision), in the case of acute intracranial hypertension, brain swelling develops very quickly with a subsequent violation of vital functions. Secondary pathology is accompanied by signs of the underlying disease.

Indirect signs may indicate the presence of CSF:

  • excessive activity, agitation;
  • deterioration of working capacity;
  • nasal bleeding;
  • pallor of the skin, bruises under the eyes;
  • decreased libido;
  • chin tremor.

Diagnostics

In the diagnosis of pathology, it is important to collect complaints and anamnesis of the patient, conduct neurological (identification of pathological reflexes and symptoms) and ophthalmologic examinations. When examining the fundus revealed dilated and tortuous veins, their plethora, swelling of the optic nerve head.

Instrumental research methods:

  • Echoencephalography. Allows you to obtain indirect data that should be compared with the clinical picture.
  • X-ray of the skull. Signs of intracranial hypertension in the form of digital impressions on the bones of the skull.
  • CT scan, MRI. Allow to assess the bones of the skull, brain tissue, its blood supply, to detect the presence of heart attacks and hemorrhages, tumors, the expansion of the ventricles of the brain and intershell spaces.
  • Ultrasound of the head and neck vessels. Helps to establish the disorder of venous outflow from the brain.

In case of idiopathic intracranial hypertension, lumbar puncture is performed followed by a study of the biochemical composition of the cerebrospinal fluid, in which the main indicators (electrolytes, sugar, proteins and cells) exceed the norm.

Also, the study of cerebrospinal fluid allows to clarify the genesis of secondary intracranial hypertension (infectious, oncological, vascular).

Important!   In case of acute pathology, lumbar puncture is contraindicated due to possible complications.

Differential diagnosis of primary intracranial hypertension is carried out with an epileptic seizure and toxic or metabolic dysfunction of the brain. In epilepsy, there is a recurrence of convulsive seizures, convulsions are clonic, there are sudden, unstable changes in heart rhythm, blood pressure. Also, convulsions during epilepsy are accompanied by salivation without swallowing (foaming out of the mouth), there is a history of epileptic seizures. In acute poisoning, generalized infections, incoherence of speech, confusion and disorientation, anxious agitation are observed.

Treatment of intracranial hypertension

The tactics of treatment of cerebrospinal fluid hypertension is determined by the cause of the increase in intracranial pressure. Therapy of this condition is done by a neurologist. Treatment can be carried out conservatively (in case of chronic intracranial hypertension or residual effects after trauma) and operatively (in case of a sharp increase in pressure, the threat of dislocation syndrome and impaired consciousness).

Conservative therapy

The basis is the appointment of diuretics, which help to reduce production and increase the absorption of cerebrospinal fluid.

Potassium-sparing diuretics (acetazolamide 2 , spironolactone) are preferred , but loop diuretic (furosemide) is allowed. Reception of diuretics prescribed together with potassium preparations (asparginate or potassium chloride) to prevent the development of hypokalemia. In severe or acute cases (significant or sudden increase in intracranial pressure), the drugs of choice are osmotic diuretics (mannitol), which have a dehydrating effect (they draw out fluid from the brain tissues, thereby reducing their swelling).  

Important!   With a BMI of more than 30, diuretics receive the greatest therapeutic effect in combination with weight loss measures.

Additionally appointed:

  • Glucocorticoids. They have a decongestant effect in the presence of formations in the brain.
  • Metabolic drugs. Improve the trophism of brain tissue (piracetam, nootropil).
  • Antiviral, antibiotics. Shown in infectious genesis of intracranial hypertension (meningitis, encephalitis).
  • Vasoactive drugs. Appointed with vascular disorders (corinfar, aminophylline).
  • Venotonics. Normalize venous outflow, eliminate venous stasis (diosmin, dihydroergocristin).

Conservative treatment of cerebrospinal fluid hypertension includes compliance with the drinking regimen (no more than 1.5 liters of fluid per day) and salt-restricted diets.

Shown massage the neck area, head and neck.

Surgery

In emergency situations, when intracranial pressure is required to be quickly reduced, surgical intervention is performed, which includes: decompression craniotomy (with inoperable brain tumors), cerebral shunting (with hydrocephalus). In some cases, repeated lumbar puncture, which is performed every 2 days, is effective.

Complications

Chronic intracranial hypertension leads to atrophy of the medulla, which affects the neuroregulation of internal organs, mental abilities (memory loss, reduced ability to concentrate, weakening of the intellect). In addition, the constant increased intracranial pressure adversely affects vision (visual impairment or loss of vision) due to optic nerve atrophy.

The most serious complication of pathology with an acute increase in intracranial pressure is considered to be the development of a dislocation syndrome (a wedge of the brain stem into the occipital foramen), which leads to respiratory arrest and impaired blood circulation and ends with a lethal outcome.

Prognosis and prevention

The prognosis of CSF depends on the rate of increase in intracranial pressure, timely and adequate treatment, as well as on individual compensatory features of the brain. With the development of dislocation syndrome, the prognosis is unfavorable, a high probability of death.

With regard to idiopathic intracranial hypertension, with regular courses of ICP lowering, the prognosis is favorable, in some cases spontaneous remission is observed.

Foreign studies show that moderate weight loss (5-10%)   may be a sufficient measure to reduce the signs and symptoms of intracranial hypertension. If lifestyle changes do not result in weight loss and decrease in ICP, the patients with a BMI of more than 40 may be recommended to reduce operation weight.

Prevention measures include timely visits to the doctor when a headache, deterioration of vision, normalization of sleep, rest, elimination of stress and unhealthy habits, maintaining a healthy lifestyle.

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