Neuro (Cerebral Perfusion Pressure)

MAP= (1 systolic + 2 diastolic)/3 

• MAP-ICP (monitor surgically placed in head)=CPP
• CPP>50 is normal

Measured in mm Mercury

• If BP 145/90 and ICP is 18, what is CCP? 
• Answer: 60

• Risk for altered tissue perfusion related to:
• Ineffective individual coping related to:
• The client will have decreased anxiety related to:
• Risk for altered thought process related to:
• Anticipatory grief related to:
• Risk for safety related to:
• Risk for discomfort related to:

Come up with some interventions...

• Most commonly caused by TBI, intracranial aneurysms and AVMs
• Saccular (berry) aneurysms are most common & development
• --hastens with HTN, atherosclerosis, aging and stress
• --usually found in anterior circle of willis

• Media thins and connective tissue replaces smooth muscles
• Vasospasm causes ischemia and infarction seems related to volume of blood degradation

• Usual very sudden onset with sudden severe HA, projectile vomiting, then loss of consciousness
• Generalized seizures may occur
• S&S of meningeal irritation (nuchal rigidity [whole spine goes stiff when lifted by head], photophobia, back pain)
• S&S relate to the artery in spasm
• MCA: hemiparesis, dysphagia
• ACA: incontinence, faulty problem solving
• PCA: hemianopia
• Review ignoral (neglect of a side of body or limb) and heminopsia (part of visual field is completely ignored.

• Best diagnostic is CT angiography
• Blood in CSF
• Most frequently seen at 7th day post hemorrhage
• 80% have enough blood to be appreciated with non-contrast CT. Other 20% will not, so might be missed. 

• Maintain CPP (vasopressors, hemodynamics monitored, prevent ischemias from hypotension)
• Control ICP
• Minimize vasospasm  (treat HTN,Hypervolemia and Hemodilution)
• Manage hydrocephalus (drains may be placed)
• Manage arrhythmias (monitor electrolytes and rhythm)
• Prevent re-bleeding

• Possible surgeries:
• --Endovascular therapies
• --Aneurysm clip (“time bomb”)
• AVMs: tangle of arteries/veins malformation. Impossible to detangle. Present like SAH when it bleeds.
• --Massive lesions that tangle veins and arteries
• --Usually in brain or spinal column
• --When bleeds, present like SAH
• --Can present with “circulatory steal”
• --Usually require surgical resection, now developing radiographic approaches to controlling AVMs
• --Care is similar to SAH with outcomes, interventions

Associated with space occupying lesion, infarction, CSF flow issue, abscess,elevated pCO2,decreased pO2

• Subtle change in LOC (restlessness,confusion, irritability)
• Change in GCS
• HA, N/V, Diplopia, changes in PERRLA
• Papilledema
• Cushing's triad: massive increased SBP, widened pulse pressure, bradycardia
• Cheyne stokes respirations, apneustic (loss of respirations)  or ataxic breathing (labored, uncoordinated breathing). Messy breathing.

• Always a medical emergency
• Herniation through open skull fractures
• Central herniation (rapid change in LOC with hyperventilation (early))
• Uncal herniation (lateral pressure on temporal lobe) has pupils that are unreactive to light with stupor and resp changes
• Infratentorial (Tonsillar) herniation is classic foramen magnum herniation with Cushing's triad and change in LOC

• Decrease ICP
• Mannitol (review this one)
• CPP/ICP monitoring
• Prevent complications
• Barbiturate coma combined with...
• ...NMB (neuromuscular blockage) agents. Done to preserve the brain and to slow blood flow to smooth muscle. 
• Nursing Care

• LOC
• VS, especially RR and pattern
• Pupils
• --Equal
• --Size
• --Position
• --Reactivity
• --Shape
• --EOM
• --Accommodation
• --Nystagmus

• Airway
• Positioning: with szr, may want to place pt on floor because they'll end up there anyway. 
• F&E/I&O (DI, then you're dry)
• Body Temp
• Monitor VS, LOC, ICP, CPP
• Nutrition: becomes a problem when pt cannot feed themselves or loses gag reflex-->npo. 
• Elimination
• Prevent complications