Neurologist at SM-Clinic spoke about intracranial pressure

Why is pressure inside the skull needed, why can it be elevated, and how does this indicator relate to blood pressure? What are the norms and when is blood pressure dangerous to health and life, how to feel it and how to reduce it, let's talk with an expert ALENA PARETSKAYA
Pathophysiologist, immunologist, WHO expert POLINA PETROSYAN Neurologist at SM-Clinic, specialist in cerebrovascular diseases and headaches

What is intracranial pressure

The brain is surrounded by a fluid called cerebrospinal fluid, which nourishes and protects nerve cells.
Cerebrospinal fluid is continuously produced and flows away from the skull, thereby maintaining a constant pressure. This is intracranial pressure - a certain force that puts pressure on the brain and the walls of the skull. This pressure is changed in mmHg. Art., and normally it is from 10 to 15 mm. If it is higher, this is a reason to be wary, and if the pressure exceeds 25 mm Hg. Art., this can be dangerous for brain function. If the value is more than 35 mmHg. Art. Severe and irreversible changes in the brain are possible - such situations are considered critical.

Causes of intracranial pressure in adults

Increased intracranial pressure (ICP) is not an independent disease, but a syndrome.
Doctors sometimes call it intracranial hypertension. Pressure inside the brain (similar to arterial pressure) fluctuates when the head is tilted back and forth or to the sides, during physical activity or sneezing. But it can increase to serious numbers in case of pathologies, and there are many of them. “ICP (intracranial pressure) occurs as a result of an increase in the volume of intracranial contents (cerebrospinal fluid or cerebrospinal fluid), tissue fluid, or the appearance of foreign tissue (tumors, cysts, brain abscess), says neurologist Polina Petrosyan.

In addition, the causes of increased ICP may be:

• traumatic brain injury;
• tumor;
• intracerebral hemorrhage;
• neuroinfections (encephalitis, meningitis).

“The cause may also be long-term use of drugs from the group of hormonal contraceptives, corticosteroids or antibiotics,” adds Dr. Polina Petrosyan.
Pressure increases because fluid is either produced in excess (for example, due to an infection that has spread to the brain or its membranes), or because fluid flows out of the skull through special pathways less easily. If volumetric processes develop in the cranial cavity (for example, a tumor grows or hemorrhage occurs), there will be less space for fluid, and its pressure will also increase.

What are the risks of increased intracranial pressure? Complications and consequences

The brain is the highest energy system in the human body. It needs approximately five times more oxygen than the heart. Therefore, the quality of blood supply to the brain is a vital indicator that depends on two parameters - blood pressure and intracranial pressure. At constant blood pressure, the lower the intracranial pressure, the better the blood supply to the brain. If for some reason intracranial pressure increases, this proportionally worsens the blood supply to the brain, and ischemia develops. Therefore, high intracranial pressure is a dangerous condition that can cause the following complications:

• reduction and complete loss of vision;
• convulsions;
• acute cerebrovascular accident;
• depression and/or disorder of consciousness;
• depression of respiratory and circulatory function.

Important! With a rapid increase in intracranial pressure, there is a threat of death. If the symptoms are severe or appear sharply, suddenly and rapidly increase, you need to call an ambulance.

Symptoms of intracranial pressure in adults

In many cases, a slight increase in ICP may not manifest itself for a long time. If the pressure rises sharply or high enough, the following symptoms may occur:

• headache - it can be pressing or bursting, usually occurs in the morning, this pain has no clear localization, it can be felt in different parts of the skull;
• nausea and vomiting - they usually occur at the peak of the headache;
• drowsiness, malaise, general poor health;
• memory impairment (forgetfulness), attention disorders, problems with thinking;
• changes in the autonomic nervous system – surges in blood pressure, slow pulse, increased sweating;
• visual impairment up to complete blindness.

Symptoms may come on suddenly or develop gradually over weeks or months.

Diagnostics

It is extremely difficult to suspect an increase in ICP based on external signs.
The doctor must know all the complaints and those facts from life that preceded the symptoms. This could be a hypertensive crisis, head injury, severe infection, kidney or liver problems. In order to confirm the diagnosis, the doctor will prescribe a number of studies to the patient: CT or MRI of the brain to evaluate the structure of all tissues of the skull, note the condition of the ventricles of the brain where cerebrospinal fluid accumulates;

• echoencephaloscopy to determine brain function;
• Ultrasound of the brain (mainly in children through the fontanelle);
• examination of the condition of the fundus by an ophthalmologist;
• spinal cord puncture with measurement of the pressure of the escaping cerebrospinal fluid (the cerebrospinal fluid itself is taken for analysis).

Make a diagnosis

Intracranial pressure can be directly measured only by inserting a special needle with a pressure gauge connected to it into the fluid cavities of the skull or spinal canal. Therefore, we do not use direct measurement of intracranial pressure.

On the left is an MRI scan of a normal brain. The brain matter is shown in gray, the cerebrospinal fluid is in white. Normal size of the fluid spaces of the brain (they are slit-like). The ventricles are visible inside the brain. The subarachnoid spaces are the white border around the brain.

In the center there is internal hydrocephalus. Excessive accumulation of cerebrospinal fluid inside the brain in the form of a butterfly is visible. On the right is external hydrocephalus. External hydrocephalus is also an excessive accumulation of cerebrospinal fluid outside the brain in the form of a wide white border. The volume of the brain matter is reduced - brain atrophy from fluid pressure

We can confidently judge the increase in intracranial pressure based on the following data:

• Dilation and tortuosity of the fundus veins is an indirect but reliable sign of increased intracranial pressure;
• Expansion of the fluid cavities of the brain (internal hydrocephalus of the brain, external hydrocephalus) and external hydrocephalus (rarefaction of the medulla) along the edge of the ventricles of the brain, clearly visible on computed x-ray tomography (CT) or magnetic resonance imaging (MRI);
• Violation of the outflow of venous blood from the cranial cavity, established using ultrasound vascular studies.

How much the brain suffers from increased intracranial pressure can be judged from EEG data. The gold standard for instrumental examination of patients in our clinic is an assessment of symptoms, brain tomography , fundus images and EEG .

Good optics helps us see the subtle nuances of the fundus vessels

Echoencephalography (Echo-EG) provides indirect and not always reliable data on increased intracranial pressure; it is less reliable than CT and MRI, so we do not use this method.

Modern methods of treatment

In some cases, the patient does not require treatment; he is observed and treated for the underlying disease, which caused the increase in ICP.
If it is necessary to treat pathology, two approaches are used - conservative and surgical.

Conservative interventions are carried out for those patients whose ICP elevation is chronic and there is no significant deterioration of the condition over time. The basis of treatment is drugs that have a diuretic effect, which reduce the volume of fluid in the head. The specific medicine is determined by the level of pressure and the situation. In severe and acute processes, osmotic diuretics (mannitol) are used, in chronic cases - furosemide, hydrochlorothiazide, spironalactone. While taking them, you need to drink a potassium preparation - Asparkam, Potassium orotate, Panangin.

Surgical methods for treating increased ICP depend on the stage and severity of the disease. In acute situations, craniotomy is performed to reduce fluid pressure on the brain and drain excess fluid. Special shunts (tubes) are installed as planned, which drain fluid from the brain into the abdominal cavity.

Retinal detachment - symptoms and treatment

Retinal detachment was an incurable disease until the 20th century. The first successes were achieved only in the 20-30s. Then, in 1951, the Belgian ophthalmologist Charles Skepens proposed a revolutionary and at that time most effective method of treating retinal detachment - scleral filling. During the operation, the location that corresponded to the retinal tear from the inside was precisely marked on the sclera. At this point, a porous silicone filling was pressed into the sclera and fixed with sutures, which, due to the pressing, blocked the flow of fluid under the retina, and the gap was closed. Fillings could be single, multiple or circular. The method of scleral drainage and drainageless filling has been successfully used by ophthalmologists around the world for more than 20 years and is often used now [20][21][30].

In the 70s, a new period began in the treatment of retinal detachment - the era of vitrectomy. The method consisted of removing the vitreous, straightening the retina, cauterizing the rupture site with a laser and tamponing the retina with various substances: air, gas-air mixtures, silicone oil, fluorine and carbon compounds. Currently, this technique has become widespread and is the main surgical method for retinal detachment [4][5][6][7].

In modern practice, as a rule, not one method of surgical treatment of retinal detachment is used, but several, depending on the type of disease, duration of occurrence and concomitant eye diseases:

1. Vitrectomy is the main treatment for retinal detachment. But it has disadvantages - after vitrectomy, cataracts almost inevitably develop within 1-12 months. Therefore, the operation is performed only according to strict indications, balancing the positive result and the risks.
2. Scleral buckling is a method that is more often used in young patients with “fresh” retinal detachment and a single break. The disadvantage of scleral filling is astigmatism and increased myopia with circular filling.

Both of these methods are usually complemented by:

• Laser coagulation of the retina - as a result of laser exposure, coagulation (partial destruction) of the retinal proteins occurs. This causes “sealing” of the problem area and stops the development of the disease, and in some cases leads to its cure.

• Cryocoagulation - installation of a probe for cold tissue burns.
• Tamponade of the vitreous chamber with air, gas-air mixtures, silicone oil to create a strong adhesion of the retina and the underlying pigment epithelium and reliably hold the retina in its anatomical place [8][13][16].

Treatment of rhegmatogenous retinal detachments

There is no conservative treatment for rhegmatogenous retinal detachments. The main method is the operation of vitrectomy - scleral filling that is as gentle as possible for the retina and surrounding tissues and closes all retinal breaks. The listed methods can be used either separately or in combination, ranging from the simplest method to the complex one [7][14][19][27].

In recent years, vitreoretinal surgery for retinal detachments has achieved high results. With timely treatment, in 90-95% of patients the retina is completely adjacent. Half of all operated patients have visual acuity of 0.4 or higher. The preservation of visual functions directly depends on the timing of retinal detachment and whether it has spread to the central region or not. The delicate photoreceptors of the central zone quickly die under the detached retina, which leads to irreversible vision loss [12][19][28][31][33].

It is important to note that the connection between the retinal neuroepithelium and the pigment epithelium, even after complete anatomical reattachment of the retina, is quite weak. Therefore, especially in the first year after surgery, there is a high risk (in 9-25% of patients) of retinal detachment, and surgery may be required again. Sometimes the patient undergoes several operations, which leads to a significant decrease in vision and a narrowing of the visual field [12][14][21].

Even if the operation was successful and the retina settled into place, about 10% of operated patients have low visual acuity due to macular edema or epiretinal fibrosis - folds form on the retina like “crumpled cellophane”. As a result, the patient sees objects unclearly and distorted, usually in a reduced form. Such situations require repeated surgery and additional medications [13][20][25][26][27][28][29].

Treatment of traction retinal detachments

Tractional retinal detachments that do not affect the central region are observed for a long time, but at the slightest suspicion of worsening the pathology, they operate using the vitrectomy method. In this case, all tractions that pull on the retina are removed, which leads to its adherence. Vitrectomy can be combined with circular episcleral filling and laser coagulation.

As a rule, patients with traction retinal detachment have diabetes. One week before vitrectomy, patients with diabetes mellitus are injected into the vitreous cavity with drugs to reduce the risk of bleeding from newly formed retinal vessels during surgery (Lucentis, Eylea) [26][28]. The development of vitreoretinopathy is also influenced by the degree of compensation for diabetes mellitus. With uncompensated diabetes mellitus, the prognosis is much worse.

A difficult task is the treatment of tractional retinal detachment in retinopathy of prematurity. As a rule, the child does not immediately go to the ophthalmology hospital, and tractional retinal detachment develops in the first weeks after birth. In the initial stages, the disease does not require surgical treatment; coagulation of the retina in areas with impaired blood flow and careful observation by an ophthalmologist once a week is sufficient. In severe stages, when partial retinal detachment appears, surgical treatment will be required. At this stage, extrascleral circular filling or vitrectomy can be performed. When almost complete or complete retinal detachment develops, only vitrectomy is performed simultaneously with lens removal.

There are often cases when a premature baby is admitted to an ophthalmology hospital with the last degree of retinopathy of prematurity. Unfortunately, in this case it is almost impossible to obtain satisfactory results for vision [10][15].

Treatment of exudative retinal detachment

When treating exudative retinal detachment, drug therapy is used for the disease that caused the inflammation. As a rule, these are uveitis of various etiologies, rheumatoid inflammatory diseases, infectious diseases, tuberculosis and AIDS. For example, for inflammatory exudative detachments caused by rheumatoid diseases, significant doses of glucocorticosteroids are actively used. In infectious diseases, retinal detachment is treated with antibacterial agents [11].

Exudative retinal detachment can be caused by a malignant tumor of the retina: retinoblastoma in children and choroidal melanoma in adults. In this case, a decision is made whether to preserve the eye as an organ or not. Organ-preserving treatment is carried out using brachytherapy (radiation therapy), thermotherapy, gamma knife (radiosurgery unit), vitrectomy with tumor endoresection (microinvasive removal) and other methods.

Rehabilitation activities

The rehabilitation period after surgical treatment of retinal detachment is not as fast as after surgical treatment of cataracts. After surgery, the patient should take eye drops for 1-1.5 months. During this period, heavy physical activity, sports, visiting the bathhouse, swimming pool, sauna are prohibited. Depending on what the vitreal cavity is tamponed with - air, gas or silicone oil, the patient is in a forced position facing down or up for the first days after the operation for complete adhesion of the retina. During the rehabilitation period, be sure to visit your ophthalmologist. During examinations, the doctor monitors the process of reattachment and restoration of the retina after surgical treatment.

Gymnastics for the eyes

Eye exercises are useless for preventing retinal detachment. In some cases, it can even be harmful, since it promotes movements of the vitreous body in the vitreal cavity and provokes traction and retinal tears.

Is treatment with folk remedies effective?

Retinal detachment is one of the most serious diseases of the visual organs, which requires urgent surgical intervention; the use of folk remedies is unacceptable. Without timely and correct treatment, the pathology leads to blindness.

Prevention of intracranial pressure in adults at home

Prevention of increased ICP is the prevention of various diseases affecting the cranial cavity.
This includes protection against infections that can affect the brain - vaccination against meningococcal and hemophilus influenzae infections, influenza vaccination. It is also necessary to treat various pathologies that can affect brain function. General recommendations are simple:

• follow a daily routine and lead the healthiest lifestyle possible;
• avoid head injuries;
• protect yourself from stress and nervous overload;
• Get enough sleep.