الفهرس 
PHYSIOLOGY OF CSF PRODUCTION AND DRAINAGEOnly 14 pages are availabe for public view
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Abstract
W
orldwide ICP monitoring has never been subjected to a prospective randomized clinical trial (PRCT) to establish its efficacy in improving outcome from severe head injury. Hence, there are insufficient data to support its use as a standard. However, there is a large body of published clinical experience that indicates that ICP monitoring
(1) Helps in the earlier detection of intracranial mass lesions.
(2) Can limit the indiscriminate use of therapies to control ICP which themselves can be potentially harmful.
(3) Can reduce ICP by CSF drainage and thus improve cerebral perfusion,
(4) Helps in determining prognosis,
(5) May improve outcome.
ICP monitoring is therefore used by most head injury experts in the United States and is accepted as a relatively low risk high-yield, modest cost intervention. Comatose head injury patients (GCS 3-8) with abnormal CT scans should undergo ICP monitoring. Comatose patients with normal CT scans have a much lower incidence of intracranial hypertension unless they have two or more of the following features at admission: age over 40, unilateral or bilateral motor posturing, or a systolic blood pressure of less than 90 mm Hg. ICP monitoring in patients with a normal CT scan with two or more of these risk factors is suggested as a guideline. Routine ICP monitoring is not indicated in patients with mild or moderate head injury.
However, it may be undertaken in certain conscious patients with traumatic mass lesions at the discretion of the treating physician.
A prospective randomized clinical trial of ICP monitoring would be extremely useful in establishing the value of this technique. However, it is not clear that such a trial will ever be performed. Most head injury experts consider ICP or CPP to be the primary basis for ICU management decisions in the care of the severe head injured patient.
However, some neurosurgeons do not routinely monitor ICP in severe head injury patients, demand proof that it makes a difference, and believe that the risks do not justify the benefits. A PRCT would require approximately 700 patients with severe head injury to demonstrate a 10% difference in mortality. One would need a multicenter trial at a cost of at least $5 million dollars. The management of the nonmonitored group would remain problematic.
Such a trial was proposed to the National Institutes of Health (NIH) a few years ago but was not funded.
There is a NIH-funded trial currently underway comparing traditional ICP management to management aimed at maintaining a certain cerebral perfusion pressure in severe head injury patients. This study may provide the type of class I data that is required without randomizing one group of patients to a non monitored arm.
On the other hand many studies has proved the efficacy of ICP monitoring as
The management of intracranial hypertension has advanced considerably since the introduction of ICP monitoring approximately 30 years ago, mainly due to advances in neurosurgical science and anesthetic practice, but assisted by developments in sensor technology and the availability and acceptance of the computer as an aid to patient management. ICP monitoring is now widely used by neurosurgeons and by clinicians concerned with the care of patients susceptible to raised ICP.
This review has described problems created in patient management by intracranial hypertension and reasons why ICP monitoring is used to advantage. Methods of measurement and a range of pressure sensing devices have been discussed, and advances in monitoring methods reviewed.
Management of intracranial hypertension presents a challenging area of work, with head injury in particular posing considerable problems. Our knowledge of the hydrodynamics of the cerebral circulation in both normal and pathological conditions continues to expand and improve. This increased understanding is continually applied to patient management through improvements in diagnostic and therapeutic techniques. Successful treatment of intracranial hypertension, however, is based initially upon measurement of the ICP, the accuracy of which is dependent upon the quality and correct usage of the sensor. Advances in sensor technology have produced improvements in accuracy and stability which, together with better understanding of the relationships between ICP measurements from different sites, continue to increase the value of the measurements acquired.
With regard to monitoring ICP the goal is to predict the onset of intracranial hypertension and, as suggested in this essay, to predict the effect of drug therapy. Work continues to develop and improve indicators of intracranial compliance based upon the dynamics of the c.s.f. pressure pulsations, and upon correlation of ICP with other clinical variables. The combination of such indicators with recent advances in monitoring methods is a particularly promising avenue of investigation since sophistication can now be incorporated within a monitor system whilst keeping the interaction with the nursing staff to a minimum. Closed-loop control of ICP through automatic injection of drugs may also become more widely adopted as an extension of such monitor systems. It is, however, of paramount importance that any new developments are critically assessed with regard to their value at the bedside. Their introduction must therefore be associated with an evaluation of methods of communicating changes and predictions of ICP to the nursing staff.
In Egypt the use of ICP monitoring is still limited due to its high cost and limited resources and still there’s many debated worldwide about its use in trauma patients.
In the mean time we can benefit from improving other approaches in management of trauma patient rather than focusing on the use of such an expensive technique as ICP monitoring which is considered as a major burden for many public health centers.
Improving and proper training of the nursing staff and doctors in the way of dealing with polytruama patients.