What is intracranial pressure (ICP)?

Intracranial pressure (ICP) refers to the pressure exerted by the cerebrospinal fluid (CSF) and blood within the skull on the brain tissue. It is a critical physiological parameter that helps maintain the brain's environment.

In what units is intracranial pressure typically measured?

Intracranial pressure is commonly measured in millimeters of mercury (mmHg). It can also be expressed in centimeters of water (cmH2O), particularly in the context of lumbar punctures.

What is the normal range for intracranial pressure in a resting, supine adult?

In a resting, supine adult, the normal intracranial pressure is typically between 7 to 15 mmHg. This range is equivalent to 9 to 20 cmH2O.

Which medical specialties are primarily involved with intracranial pressure?

The medical specialties most concerned with intracranial pressure are Neurosurgery and Neurology.

What are the three main types of intracranial pressure mentioned?

The three types of intracranial pressure described are increased, normal, and decreased.

How does the body normally maintain stable intracranial pressure?

The body employs various mechanisms to keep ICP stable. For instance, CSF pressure fluctuates slightly in normal adults through adjustments in the production and absorption rates of CSF, and these pressures can also be influenced by changes in intrathoracic pressure during actions like coughing or the Valsalva maneuver.

What is intracranial hypertension (IH), and what are its common alternative names?

Intracranial hypertension (IH), also known as increased ICP (IICP) or raised intracranial pressure (RICP), is a condition characterized by elevated pressure within the cranium.

What pressure levels are generally considered the upper limit of normal for ICP, and when is treatment typically initiated?

A pressure of 20-25 mmHg is considered the upper limit of normal for intracranial pressure, beyond which treatment may be necessary. However, it is common practice to begin treatment when ICP exceeds 15 mmHg.

What are the general signs and symptoms that suggest a rise in intracranial pressure?

General signs and symptoms suggesting increased ICP include headache, vomiting without nausea, ocular palsies, altered level of consciousness, back pain, and papilledema (swelling of the optic disc).

What can happen if papilledema is prolonged?

If papilledema persists, it can lead to visual disturbances, optic atrophy, and eventually blindness.

Describe the characteristics of a headache associated with raised ICP.

Headaches associated with raised ICP are classically described as morning headaches that can wake the individual. They tend to worsen with activities like coughing, sneezing, or bending over, and progressively worsen over time. This pattern is partly due to mild hypoventilation during sleep leading to hypercapnia and vasodilation, and cerebral edema potentially worsening when lying down.

What additional signs may appear if there is mass effect causing brain tissue displacement?

If mass effect is present and causes brain tissue to shift, additional signs may include pupillary dilatation, abducens nerve palsies (sixth nerve palsies), and Cushing's triad.

What are the components of Cushing's triad?

Cushing's triad consists of three key physiological changes: increased systolic blood pressure, a widened pulse pressure, and bradycardia (slow heart rate). An abnormal respiratory pattern can also be present.

What is intracranial hypertension syndrome characterized by?

Intracranial hypertension syndrome is defined by elevated ICP, papilledema, and headache, sometimes accompanied by abducens nerve paresis. Importantly, it occurs in the absence of a space-occupying lesion or ventricular enlargement, and with normal cerebrospinal fluid chemical and hematological constituents.

How can irregular respirations indicate brain injury related to ICP?

Irregular respirations can occur when brain injury affects the respiratory drive. For example, Biot's respiration (alternating periods of rapid breathing and apnea) may indicate damage to the cerebral hemispheres or diencephalon, while hyperventilation might suggest damage to the brain stem or tegmentum.

At what ICP levels does consciousness typically remain intact, and when does loss of consciousness occur?

Patients with normal blood pressure generally retain normal alertness with ICP levels between 25-40 mmHg, unless there is concurrent tissue shifting. Loss of consciousness typically occurs when ICP exceeds 40-50 mmHg, as this level significantly decreases cerebral perfusion pressure (CPP) and cerebral blood flow.

What are the consequences of ICP exceeding 40-50 mmHg?

When ICP exceeds 40-50 mmHg, it can lead to a decrease in cerebral perfusion pressure (CPP) to a level that results in loss of consciousness. Further elevations can cause brain infarction and ultimately brain death.

How do the signs of increased ICP differ in infants and young children compared to adults?

In infants and young children, the cranial sutures have not yet fused. Therefore, instead of a rigid increase in pressure, their fontanels (soft spots on the skull) may bulge when ICP becomes too high, allowing for some expansion.

What is the relationship between intracranial pressure and intraocular pressure?

Intracranial pressure (ICP) correlates with intraocular pressure (IOP). However, this correlation is generally not considered accurate enough for close management of ICP, especially in the acute post-traumatic period.

What are some causes of increased intracranial pressure due to mass effect?

Causes of increased ICP due to mass effect include brain tumors, cerebral edema associated with infarction, contusions, subdural or epidural hematomas, and brain abscesses. These conditions can deform adjacent brain tissue.

What conditions can lead to generalized brain swelling and increased ICP?

Generalized brain swelling, which increases ICP, can occur in conditions such as ischemic-anoxia states, acute liver failure, hypertensive encephalopathy, hypercarbia (high carbon dioxide levels), and Reye hepatocerebral syndrome. These conditions primarily decrease cerebral perfusion pressure with minimal tissue shifts.

What can cause an increase in venous pressure leading to elevated ICP?

Elevated ICP due to increased venous pressure can result from venous sinus thrombosis, heart failure, or obstruction of the superior mediastinal or jugular veins.

How can obstruction of CSF flow or absorption lead to increased ICP?

Obstruction of cerebrospinal fluid (CSF) flow or absorption can cause increased ICP in conditions like hydrocephalus (e.g., due to Arnold-Chiari malformation blocking ventricles or the subarachnoid space), extensive meningeal diseases (like infections, carcinoma, granuloma, or hemorrhage), or blockage in the cerebral convexities and superior sagittal sinus, which impairs CSF absorption.

What factors can lead to increased CSF production, thereby raising ICP?

Increased production of cerebrospinal fluid (CSF), which can raise ICP, may occur in cases of meningitis, subarachnoid hemorrhage, or a choroid plexus tumor.

What is idiopathic intracranial hypertension?

Idiopathic intracranial hypertension (IIH) is a condition where intracranial pressure is elevated for unknown reasons. It is a common cause of high ICP in otherwise healthy individuals, particularly younger women.

How is craniosynostosis related to intracranial pressure?

Craniosynostosis, a condition where the skull sutures fuse prematurely, can lead to increased intracranial pressure because the skull cannot expand to accommodate normal brain growth.

What is drug-induced intracranial hypertension (DIIH)?

Drug-induced intracranial hypertension (DIIH), also known as medication-induced intracranial hypertension, is a condition where elevated ICP is primarily caused by a specific drug. It shares similarities with idiopathic intracranial hypertension but has a known pharmacological cause.

What are the common symptoms of drug-induced intracranial hypertension (DIIH)?

The most frequent symptoms of DIIH include headaches, pulsatile tinnitus (ringing in the ears that pulses with the heartbeat), diplopia (double vision), and impaired visual acuity.

What are the observable signs of DIIH?

The primary observable signs of DIIH can be papilledema (swelling of the optic disc) and bilateral sixth cranial nerve (abducens) palsies.

What is spontaneous intracranial hypotension?

Spontaneous intracranial hypotension is a condition that may occur due to an undetected leak of cerebrospinal fluid (CSF) from the spine. It can also result from medical procedures involving the spinal cord, such as a lumbar puncture.

How is persistent intracranial hypotension, often resulting from a lumbar puncture, treated?

If persistent intracranial hypotension is caused by a lumbar puncture, a common treatment is an epidural blood patch, which helps to seal the site of CSF leakage. Intravenous administration of caffeine and theophylline has also shown some utility.

What are the diagnostic criteria for spontaneous intracranial hypotension according to the ICHD?

The International Classification of Headache Disorders (ICHD) criteria for spontaneous intracranial hypotension include headache attributed to low CSF pressure or leakage, a temporal relationship between the headache and the low CSF pressure/leakage, and no other diagnosis explaining the headache. In rare cases without headache, neurological symptoms must be attributable to low CSF pressure.

How is cerebral perfusion pressure (CPP) calculated?

Cerebral perfusion pressure (CPP) is calculated by subtracting the intracranial pressure (ICP) from the mean arterial pressure (MAP): CPP = MAP - ICP. This value represents the pressure of blood flowing to the brain.

What is the primary danger of increased ICP in relation to CPP?

The main danger of increased ICP is that it can decrease cerebral perfusion pressure (CPP), potentially leading to cerebral ischemia (lack of blood flow) and brain infarction. When ICP approaches mean systemic pressure, cerebral perfusion is severely compromised.

What is midline shift, and why is it dangerous?

Midline shift is a dangerous consequence of severely raised ICP, often caused by unilateral swelling (e.g., from a hematoma). It occurs when brain tissue is pushed across the midline of the skull, potentially compressing ventricles, leading to hydrocephalus, and causing herniation.

What is the Monro-Kellie hypothesis?

The Monro-Kellie hypothesis describes the pressure-volume relationship within the skull. It states that the cranial compartment is rigid and has a fixed volume. Therefore, any increase in the volume of one intracranial component (like blood, CSF, or brain tissue) must be compensated by a decrease in the volume of another to maintain a stable ICP.

How does the Monro-Kellie hypothesis apply differently to infants compared to adults?

The Monro-Kellie hypothesis primarily applies to adults because their cranial sutures are fused, making the skull inelastic. In infants, the presence of unfused fontanelles and sutures allows for some expansion of the cranial volume, modifying the strict application of the hypothesis.

What are the primary buffers for increased intracranial volume according to the Monro-Kellie hypothesis?

The main buffers for increased intracranial volume are cerebrospinal fluid (CSF) and, to a lesser extent, blood volume. These buffers can be displaced or reduced to accommodate changes in other intracranial contents.

Who are the physicians credited with the Monro-Kellie hypothesis?

The Monro-Kellie hypothesis is named after two Edinburgh doctors: Alexander Monro and George Kellie.

What is the most definitive method for measuring intracranial pressure?

The most definitive way to measure intracranial pressure is by using transducers placed directly within the brain, often via a catheter inserted into one of the lateral ventricles.

What is an external ventricular drain (EVD), and what is its function?

An external ventricular drain (EVD) is a catheter surgically inserted into one of the brain's lateral ventricles. It can be used to drain cerebrospinal fluid (CSF) to reduce elevated intracranial pressure (ICP), though it is typically reserved for situations like brain injury or post-surgery.

In what situations might CSF drainage via lumbar puncture be used for ICP management?

Drainage of CSF through a lumbar puncture can be used as a treatment method to reduce ICP, particularly in cases of idiopathic intracranial hypertension where only small amounts of CSF need to be removed.

What is the general principle guiding the treatment of increased ICP?

The treatment for increased ICP is highly dependent on its underlying cause. Key considerations involve managing the primary condition and addressing factors that acutely raise ICP, especially in cases of stroke and cerebral trauma.

What medication is commonly used for long-term management of raised ICP, particularly in idiopathic intracranial hypertension (IIH)?

For chronic forms of raised ICP, such as idiopathic intracranial hypertension (IIH), a diuretic medication called acetazolamide is frequently used.

How is dexamethasone used to manage ICP in patients with brain neoplasms?

Dexamethasone is administered to decrease ICP in patients with confirmed brain neoplasms. While the exact mechanism is not fully understood, it is believed to reduce peritumoral water content and local tissue pressure, thereby lowering ICP.

Why is maintaining adequate airway, breathing, and oxygenation crucial for patients with high ICP due to acute injury?

Inadequate blood oxygen levels (hypoxia) or excessively high carbon dioxide levels (hypercapnia) cause cerebral blood vessels to dilate. This increases blood flow to the brain, which in turn raises ICP, exacerbating the problem. Additionally, hypoxia forces brain cells into anaerobic metabolism, producing lactic acid and lowering pH, further dilating blood vessels.

What is the role of hyperventilation in managing ICP, and why is its use limited?

Hyperventilation, achieved by increasing a patient's breathing rate, can temporarily reduce ICP by constricting cerebral blood vessels. However, this constriction limits blood flow to the brain, which can be detrimental when the brain is already ischemic. Due to these risks and the brain's adaptation over time, hyperventilation is no longer a standard primary treatment for traumatic brain injuries but may be used in severe, refractory cases or signs of herniation.

How can elevating the head of the bed help manage ICP?

Raising the head of the bed can help lower ICP by improving venous drainage from the brain. However, this maneuver must be balanced, as it can also potentially reduce blood pressure to the head, possibly leading to inadequate brain supply.

What is the rationale behind increasing mean arterial pressure (MAP) in managing ICP?

In some cases, particularly when ICP is high, mean arterial pressure (MAP) may be intentionally increased. The goal is to maintain or increase cerebral perfusion pressure (CPP = MAP - ICP), ensuring adequate blood flow and oxygenation to brain tissues, which can help reduce swelling.

What is osmotherapy, and what agents are used?

Osmotherapy is a treatment used to decrease ICP when the blood-brain barrier is intact. It involves administering hyperosmolar agents such as mannitol or hypertonic saline, which draw excess fluid out of the brain tissue.

What is the purpose of using analgesia and sedation in ICP management?

Analgesia and sedation are used to reduce agitation, restlessness, and seizures in patients with elevated ICP. These measures help decrease the brain's metabolic demands and oxygen consumption, which can indirectly lower ICP. However, these medications can also cause side effects like low blood pressure.

Intracranial Pressure Wiki: Cerebral Pressure Dynamics: Understanding Intracranial Pressure

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Defining Intracranial Pressure

The Cranial Environment

Intracranial pressure (ICP) refers to the hydrostatic pressure exerted by the cerebrospinal fluid (CSF) within the cranial cavity and upon the brain tissue. It is typically quantified in millimeters of mercury (mmHg). In a resting adult in a supine position, the normal ICP range is approximately 7 to 15 mmHg, which corresponds to 9 to 20 cmH₂O on a scale frequently used during lumbar punctures.¹

Maintaining Stability

The human body employs sophisticated mechanisms to maintain ICP within a stable range. CSF pressure demonstrates remarkable stability, fluctuating by only about 1 mmHg in healthy adults through dynamic adjustments in CSF production and absorption rates. These regulatory processes are crucial for protecting the brain from pressure fluctuations.

Factors Influencing ICP

Variations in ICP are directly linked to changes in the volume of the cranial constituents: CSF, blood, and brain tissue itself. External factors such as intrathoracic pressure changes (e.g., during coughing or the Valsalva maneuver) and the interplay with the venous and arterial vascular systems can significantly influence ICP levels.

Recognizing Elevated ICP

Common Neurological Indicators

A rise in intracranial pressure often manifests with a constellation of symptoms. These classically include persistent headaches, particularly those that are worse in the morning or upon waking, and vomiting that is not preceded by nausea. Ocular disturbances, such as palsies affecting eye movement, and a general alteration in the level of consciousness are also significant indicators.³

Ocular and Systemic Signs

Papilledema, the swelling of the optic disc, is a key sign of elevated ICP. While vision may initially remain unaffected, prolonged papilledema can lead to optic atrophy and eventual blindness. Systemic signs, particularly in cases of significant mass effect, may include pupillary dilation, abducens nerve palsies, and the characteristic Cushing's triad: elevated systolic blood pressure, widened pulse pressure, bradycardia, and abnormal respiratory patterns.³

Pediatric Considerations

In infants, whose cranial sutures have not yet fused, elevated ICP presents differently. The fontanelles, or soft spots on the skull, may bulge noticeably. The brain's response to pressure changes can also affect respiratory patterns, with injuries to the brainstem or diencephalon potentially leading to irregular breathing such as Biot's respiration.⁶

Etiologies of Pressure Imbalance

Space-Occupying Lesions

Conditions that occupy space within the cranial vault are primary drivers of increased ICP. These include brain tumors, areas of infarction accompanied by edema, contusions, and the accumulation of blood such as subdural or epidural hematomas, as well as abscesses. These entities can deform adjacent brain tissue.¹⁰

Generalized Swelling and Venous Issues

Widespread brain swelling, observed in states of ischemic-anoxia, acute liver failure, hypertensive encephalopathy, hypercapnia, and Reye syndrome, can elevate ICP. Additionally, increased venous pressure, resulting from venous sinus thrombosis or obstruction of major mediastinal or jugular veins, impedes venous outflow and contributes to higher ICP.⁹

CSF Flow Obstruction

Disruptions in the normal flow or absorption of cerebrospinal fluid are significant causes of elevated ICP. This can occur in hydrocephalus due to blockages within the ventricular system or subarachnoid space (e.g., Arnold-Chiari malformation). Extensive meningeal disease, including infections, carcinomas, or hemorrhages, can also impede CSF absorption.

Idiopathic and Other Causes

In some instances, elevated ICP occurs without an identifiable cause, a condition known as Idiopathic Intracranial Hypertension (IIH), which is particularly prevalent among younger women.⁴ Other causes include increased CSF production (e.g., from meningitis or tumors) and congenital conditions like craniosynostosis, where premature fusion of cranial sutures restricts skull growth.

Mechanisms of Pressure Injury

Cerebral Perfusion Pressure (CPP)

Cerebral perfusion pressure (CPP), the pressure driving blood flow to the brain, is normally maintained by autoregulation. It is calculated as CPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP). Elevated ICP critically reduces CPP, potentially leading to cerebral ischemia. The body's compensatory response, raising systemic blood pressure and dilating cerebral vessels, can paradoxically worsen ICP, creating a dangerous cycle.¹²⁰

Tissue Shift and Herniation

When ICP rises significantly, particularly due to unilateral space-occupying lesions, it can cause midline shift—the dangerous displacement of brain structures. This shift can compress ventricles, leading to hydrocephalus, and ultimately result in brain herniation, a life-threatening condition where brain tissue is forced through openings in the skull.²¹

The Monro-Kellie Hypothesis

This hypothesis posits that the cranial vault is a fixed, inelastic compartment. The total volume of its contents—CSF, blood, and brain tissue—is constant. Therefore, any increase in the volume of one component must be compensated by a decrease in the volume of another to maintain equilibrium. This principle primarily applies to adults, as infants possess more compliant skulls.²²²³²⁴

The Monro-Kellie Doctrine

Volume Equilibrium

Named after Alexander Monro and George Kellie, this doctrine describes the pressure-volume relationship within the cranium. The primary buffers for volume changes are CSF and, to a lesser extent, blood volume. Initial increases in volume are compensated by the displacement of CSF and venous blood. Brain tissue itself may also offer some buffering capacity through cell volume regulation.²⁴²⁵

Adult vs. Infant Compliance

It is crucial to note that the Monro-Kellie hypothesis is strictly applicable to adults whose cranial sutures have fused. In infants, the presence of fontanelles and unfused sutures allows for expansion of the cranial volume, altering the pressure-volume dynamics and providing a different compensatory mechanism.

Diagnosing Intracranial Pressure

Definitive Measurement

The most accurate method for measuring ICP involves the surgical insertion of a catheter directly into the brain's ventricular system. This external ventricular drain (EVD) not only measures pressure but can also be used to withdraw CSF, thereby reducing ICP. This invasive procedure is typically reserved for critical care settings, such as following severe brain injury or neurosurgery.¹⁰

CSF Drainage and Non-Invasive Methods

For conditions like idiopathic intracranial hypertension, where ICP is elevated but less acutely critical, CSF can be drained via lumbar puncture as a therapeutic measure. Research is also ongoing into non-invasive techniques for monitoring ICP, aiming to provide safer and more accessible assessment methods.²⁸

Therapeutic Interventions

Airway and Ventilation Management

In acute settings, particularly following traumatic brain injury, maintaining adequate airway, breathing, and oxygenation is paramount. Hypoxia and hypercapnia can exacerbate ICP by causing cerebral vasodilation. While hyperventilation was historically used to constrict cerebral vessels and lower ICP, its use is now more restricted due to potential risks of reduced cerebral blood flow, reserved for refractory cases or signs of herniation.³¹

Pharmacological Approaches

Medications play a key role. Acetazolamide is a diuretic used for chronic conditions like IIH. Dexamethasone may be administered for brain neoplasms to reduce surrounding edema. Osmotic agents like mannitol or hypertonic saline are employed to decrease ICP, though their impact on long-term outcomes remains under investigation.³⁴³⁵ Sedatives and analgesics help manage agitation and reduce metabolic demand, but must be carefully balanced against potential hypotension.¹⁰

Surgical Interventions

Surgical options include craniotomies to remove space-occupying lesions like hematomas or to directly relieve pressure. A more drastic measure is decompressive craniectomy, where a portion of the skull is removed to allow the brain to swell without causing herniation. The removed bone flap can be stored (e.g., in the abdomen) for later reimplantation (cranioplasty).¹⁰³⁷

Associated Concepts

Brain Trauma Foundation

The Brain Trauma Foundation is a leading organization dedicated to improving outcomes for patients with traumatic brain injuries through research, education, and advocacy.

Pressure Reactivity Index (PRx)

The PRx is a measure that reflects the dynamic relationship between cerebral blood flow and ICP. It quantizes the brain's ability to maintain stable perfusion pressure in the face of fluctuating ICP, providing insights into cerebrovascular autoregulation.

Copper Beaten Skull

This term refers to a characteristic pattern of skull X-rays seen in infants with chronic increased ICP, where the sutures separate and the skull vault develops a beaten-metal appearance due to increased pressure.

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References

Sanders MJ and McKenna K. 2001. Mosby's Paramedic Textbook, 2nd revised Ed. Chapter 22, "Head and Facial Trauma." Mosby.

Pediatric Head Trauma at eMedicine

Papilledema at eMedicine

Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology at eMedicine

Initial Evaluation and Management of CNS Injury at eMedicine

Traumatic Brain Injury in Children at eMedicine

Head Trauma at eMedicine

A full list of references for this article are available at the Intracranial pressure Wikipedia page

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Cerebral Pressure Dynamics

💡 Dive in with Flashcard Learning! 💡

Defining Intracranial Pressure 🌡️

🧠 The Cranial Environment

⚖️ Maintaining Stability

📈 Factors Influencing ICP

Recognizing Elevated ICP ⚠️

🤕 Common Neurological Indicators

👁️ Ocular and Systemic Signs

👶 Pediatric Considerations

Etiologies of Pressure Imbalance 💡

💥 Space-Occupying Lesions

🌊 Generalized Swelling and Venous Issues

💧 CSF Flow Obstruction

❓ Idiopathic and Other Causes

Mechanisms of Pressure Injury ⚙️

🩸 Cerebral Perfusion Pressure (CPP)

➡️ Tissue Shift and Herniation

📚 The Monro-Kellie Hypothesis

The Monro-Kellie Doctrine 📜

⚖️ Volume Equilibrium

👶➡️🧑 Adult vs. Infant Compliance

Diagnosing Intracranial Pressure 🩺

🔬 Definitive Measurement

💧 CSF Drainage and Non-Invasive Methods

Therapeutic Interventions ⚕️

🌬️ Airway and Ventilation Management

💊 Pharmacological Approaches

✂️ Surgical Interventions

Associated Concepts 🔗

🧠 Brain Trauma Foundation

⚖️ Pressure Reactivity Index (PRx)

🦴 Copper Beaten Skull

Teacher's Corner 🧑‍🏫

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❓ Test Your Knowledge! ❓

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References

📜 References

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Disclaimer ⚠️

📜 Important Notice

Dive in with Flashcard Learning!

Defining Intracranial Pressure

The Cranial Environment

Maintaining Stability

Factors Influencing ICP

Recognizing Elevated ICP

Common Neurological Indicators

Ocular and Systemic Signs

Pediatric Considerations

Etiologies of Pressure Imbalance

Space-Occupying Lesions

Generalized Swelling and Venous Issues

CSF Flow Obstruction

Idiopathic and Other Causes

Mechanisms of Pressure Injury

Cerebral Perfusion Pressure (CPP)

Tissue Shift and Herniation

The Monro-Kellie Hypothesis

The Monro-Kellie Doctrine

Volume Equilibrium

Adult vs. Infant Compliance

Diagnosing Intracranial Pressure

Definitive Measurement

CSF Drainage and Non-Invasive Methods

Therapeutic Interventions

Airway and Ventilation Management

Pharmacological Approaches

Surgical Interventions

Associated Concepts

Brain Trauma Foundation

Pressure Reactivity Index (PRx)

Copper Beaten Skull

Teacher's Corner

True or False?

Test Your Knowledge!

Gamer's Corner

Discover other topics to study!

References

Feedback & Support

Disclaimer

Important Notice