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Monro-Kellie 2.0
PresentatieMDO17-08-2016L.L.A.Bisschops
Thedynamic vascular andveneuspathophysiological components ofICP
Wilson, Journal of Cerebral Blood Flow &Metabolism, 2016
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1783‘Science ofICP’
AlexanderMonro1733-1817
Monro described theskull asarigid structurecontaining incompressible brain andstated thatthevolumeofblood mustremain constantunless:‘wateror other matteriseffused orsecreted from theblood-vessels’inwhich case‘aquantity ofblood,equal inbulktotheeffusedmatterwill be pressed outofthecranium’.
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1824‘Science ofICP’Confirmation ofMonro’s doctrineinhuman andanimal studies:cerebral (inparticular,venous)blood volumewassimilar no matterwhat thecause ofdeath (hanging,exsanguination)was.
GeorgeKellie1720-1779
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ATLSCourseManual 9thedition
Cushing doctrine:sum ofvolumeofthebrain,blood andCSFisconstant.
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This description fails toexplain theimportance ofvolumeflow
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Thedynamic components ofICP
StaticMonro-Kellie doctrine:Equal weighting toblood andCSFmisses thedynamic reality.
Averagemalebrain volume1473ml(brain/CSF/blood)Intracranial blood volume:100-130mlCSFvolume:75ml
Slowandsteady production ofCSF (≈0.35ml/min)Substantial,continuous blood inflow andoutflow(≈700ml/min,14%ofCO)
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Thedynamic components ofICPNormal ICP≈5-15mmHg
- Greatly influenced by orthostatic postition(ICPcan be negativewhen standingup).
- Generally similar tocerebral venouspressures (if no distalobstruction).
Dynamic components:Arterial influence on ICPVenous influence on ICPExtracranial causes ofcerebral venous hypertension
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Thedynamic components ofICPArterial influence on ICP
CPP=MAP- ICPICP=MAP- CPP;implies no venous involvementGuidelines:MAP>80-90,RRsyst >90mmHgHowever:Cerebral Blood Flow resulting fromanyMAPwill differ betweenindividuals (autoregulation,PaCO2)
‘static’viewoffactorsregulating ICP,andfocuson arterial inflow alone,ledtoneglect ofimportantinfluence ofcerebral veins
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Thedynamic components ofICPVenous influence on ICP
CorticalDeeper (anterior)Central(thalamic)
Nomuscular wall:vulnerable tocompression
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Thedynamic components ofICPArole forveinsinfluencing ICP
Failure for (intra- andextracranial)venous efferent flow toprecisely matcharterial afferent flow yields immediate anddramaticchanges inintracranialvolumeandpressure.
asCBF↑,venous drainage↑,with limited venous distension IVPwill riseupstream,andthus ICP(similar toMonro-Kellie doctrine).
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Causes ofraised cerebral venouspressure
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Diffusecompression ofthevenous system
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Concurrentacutesubdural removementandsplenectomy
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Relative venous outflow restriction
Intracraniallyisolateddiffuse
Extracranially
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ConclusionBalance between cerebral inflow andoutflow isvital
Restrictions inoutflow can be assignificantasmass accumulation within thecranium
Concentration ofinterestinICP/CPP,neglect for venous side
ICPisafunction ofvenous outflow:acombination ofintra-cerebral resistance,andcervical,thoracic andabdominal pressures
If no resistance tovenous outflow:ICP=0.IVfluids to‘maintain CPP’increaseCVPandcanworsen ICP