European Journal of Anaesthesiology 2008; 25 (Suppl 42): 192–195

r 2008 Copyright European Society of Anaesthesiology

doi: 10.1017/S0265021508003517

Original Article

Intracranial pressure monitoring

R. Stefini*, F. A. Rasuloy

University of Brescia, Spedali Civili, *Department of Neurosurgery, y Institute of Anesthesiology and Intensive Care,
Piazzale Spedali Civili, Brescia, Italy

Summary
Recent studies have demonstrated that bedside cranial burr hole and insertion of intraparenchymal catheters
for intracranial pressure monitoring performed by intensive care physicians is a safe procedure, with a
complication rate comparable to other series published by neurosurgeons. The overall morbidity rate is
comparable to, or even lower than, that caused by central vein catheterization. The procedure is also quite
simple and modern disposable intracranial procedural kits are available. After the skin is prepped the land-
mark for skin incision, called the ‘Kocher’s point’, located about 2–4 cm lateral to the midline (mid-pupillary
line) and 2–3 cm anterior to the coronal suture, is found. Then the surgical field is prepared with the sterile
drapes and the skin infiltrated with local anaesthetic (0.5% lidocaine with 1 : 200 000 epinephrine). After skin
incision and retraction of the skin and subcutaneous tissue, the periosteum should be scraped off in order
expose the skull. The skin is then divaricated, exposing the underlying bone. The hole is drilled with either an
electric drill or a twist drill (the drilling procedure must be performed with the drill held within 108 of the
perpendicular position to the incision site). The hole is then irrigated with sterile saline and an 18-G spinal
needle may be used to open the dura (exercise caution when perforating the dura so as to avoid damage to the
underlying structures). Following opening of the dura, the Bolt, containing a stylet, is screwed manually into
the skull at approximately 5 mm to 1 cm for adults. The stylet is then removed after the bolt has been screwed
in, after which the bolt should be filled with saline. Finally, the zeroing of the transducer is performed by
simply holding the tip in air while zeroing on the monitor. The transducer is inserted inside the bolt and the
screw tightened. The intracranial pressure value can then be read.

Keywords: INTRACRANIAL PRESSURE; MEASUREMENT AND MONITORING; TREPHINING; OPERATIVE

PROCEDURE.

Introduction Within the cranium, since the brain is enclosed

in a non-expandable case of bone, any change in the
In the normal situation without the presence of
volume of one component (brain tissue, blood, CSF)
pathology, intracranial pressure (ICP) may undergo
will necessitate compensatory changes in the
rises without any physiopathological effect on the
volume of one or more of the other components in
brain. Abrupt increases in ICP may occur after
order for the ICP to remain constant. This is
sneezing, coughing and straining without any
expressed as the Monroe–Kelly doctrine.
consequences or neurological impairment. However,
The brain uses compensatory mechanisms in
in the presence of pathology, rises in ICP may
order to maintain the ICP constant, which are
become symptomatic and alter brain physiology.
shunting CSF to the spinal subarachnoid space,
increasing CSF absorption, decreasing CSF pro-
Correspondence to: Frank Rasulo, Institute of Anesthesiology and Intensive duction or shunting venous blood out of the
Care, University of Brescia, Spedali Civili, Piazzale Spedali Civili, 1 – 25125
Brescia, Italy. E-mail: frank.rasulo@gmail.com; Tel: 139 030 3995 560; Fax:
skull. When these mechanisms are not present or
139 030 3995 779 exhausted, there will be a sharp rise in the ICP,
 Intracranial pressure monitoring 193

leading to herniation of brain tissue downward Components

through the Foramen Magnum. As this happens,
Preparation components
blood will cease to flow to the brain and brain tissue
hypoxia, ischaemia, infarction, necrosis and death 1. Double edge razor, iodine, gauze sponges
will occur. ICP is a reflection of the relationship
Cranial access preparation
between alterations in the craniospinal volume and
the ability of the craniospinal axis to accommodate 1. Ruler, marking pen, fenestrated drape, tensoplast
added volume. The relationship between volume barrier
and pressure in the intracranial space may be expres-
Cranial access
sed as a pressure–volume curve. Standard physio-
logic nomenclature defines compliance as the 1. Xylocaine (1%, 1 : 200 000 epinephrine), syringe
change in volume for a given change in pressure and 25-G needle, scalpel
DV/DP), reflecting both the viscoelastic properties, 2. Periostium scraper, drill (hand operated or
or stiffness, of the intracranial content and the battery powered), 2.7 mm drill bit with stop
functioning of compensatory mechanisms available and wrench
to reduce ICP at any given point on the curve. 3. 5.8 mm drill bit with stop and wrench (for
The decision to monitor ICP is usually made on a ventricolostomy), bone wax, mosquito forceps
clinical and imaging basis; the clinical situation
Wound closing/dressing
must provide indications, and radiologic imaging
studies must corroborate the indications and con- 1. 2.0 silk suture, 3.0 nylon suture, needle holder,
firm the safety of the proposed monitor placement. serrated, Adson forceps, Adson forceps with
Imaging techniques also provide warning of situa- teeth, suture scissors
tions, such as mass lesions of the temporal lobes, in
which ICP measurement may fail to reflect the
progression of pathologic events. Prep
Measuring the ICP enables to determine the The skin is shaven and prepped with an iodine-
interventions that are necessary to prevent secondary based antiseptic solution. The right side is preferred
brain injury, which can lead to brain damage and for the insertion of the bolt screw, since the motor
death. If the intracranial pressure increases above cortex is most commonly found on the left; how-
20–25 mmHg, therapeutic interventions, medical ever, this latter side can be used if access is not
and/or surgical, should be initiated. This is because possible on the right.
as the ICP increases, it gradually becomes more
difficult for the blood to be pumped to the head to Landmark for incision and bolt insertion
perfuse the brain tissue. The landmark for the skin incision called ‘Kocher’s
Monitoring techniques have grown safer, less point’ should be found (Fig. 1).
expensive and more sophisticated, and our under-
standing of intracranial pathophysiology has Kocher’s point
improved. There are several different ways to mea- The bolt should be placed in the mid-pupillary
sure the pressure within the compartment of the line (2–4 cm or two fingerbreadths lateral to the
skull. These methods may include subdural, paren- midline) and 2–3 cm anterior to the coronal suture
chymal or intraventricular pressure monitoring. (fingerbreadth in front of the coronal suture, mid-
They may be used to monitor the pressure or to pupillary line). The coronal suture can sometimes
drain CSF. Intraparenchymal catheters used to be palpated; however, if that is not possible, its
measure ICP are relatively precise and associated location can be estimated by following a line
with a low complication rate. up midway between the lateral canthus and the
A recent study has demonstrated that bedside external auditory meatus.
insertion of an ICP monitor performed by intensive
care physicians is a safe procedure, with a complication Drape
rate comparable to other series published by
neurosurgeons [1–4]. The overall morbidity rate is Sterile drapes should be placed to define the extent
comparable to, or even lower than, that caused by of the surgical field.
central vein catheterization. The most modern and
common Cranial Access Kits available are disposable Local anaesthetic
intracranial procedural kits, which contain the basic Skin infiltration using 0.5% lidocaine with
items used during each step of the cranial access 1 : 200 000 epinephrine from a syringe with a 25-G
procedure. needle.

r 2008 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 25 (Suppl 42): 192–195
194 R. Stefini and F. A. Rasulo

Loosen the drill guide using the appropriate hex

wrench. Carefully slide the drill guide towards the
tip of the drill bit until the determined skull depth
is reached.
Warning: The drill guide will not stop the drill.
The guide is designed only to provide the neuro-
surgeon with a marker for drilling depth. The guide
must be adjusted to the proper position prior to
drilling. Tighten the drill guide in place with the
hex wrench. Begin the drilling procedure.

Cranial tissue layers

Several layers of soft and bony tissue must be
crossed to reach the intracranial space from the skin
Figure 1. surface. The layers, from superficial to deep, are the
Kocher’s point: mid-pupillary line (2–4 cm or two fingerbreadths scalp (skin, connective tissue-dense, aponeurosis,
lateral to the midline) and 2–3 cm anterior to the coronal suture loose connective tissue pericranium), bone, dura,
(fingerbreadth in front of coronal suture, mid-pupillary line). arachnoid, pia and brain.
Surgeon position
The surgeon should stand at the head of the bed and Drilling
should wear a face mask and cap as well as sterile After stripping away the periosteum, a hole is
gloves and a gown. drilled. The hole is then irrigated with sterile saline
and an 18-G spinal needle is used to open the dura
Patient position in a cruciate fashion. The drilling procedure must
Supine with head facing directly forward and held be performed with the drill held within 108 of the
in place with tape. The head of the bed can be perpendicular position to the incision site. Exercise
elevated as desired. caution when perforating the dura so as to avoid
damage to the underlying structures (Fig. 2).
Sedation/analgesia
The patient should be sufficiently sedated prior to Bolt placement
beginning the insertion. Following opening of the dura, the bolt is screwed
manually into the skull. This will be approximately
Assistant 2–3 mm for the neonatal age group, 3–5 mm for the
Should help hold the head of the patient during paediatric age group and 5 mm to 1 cm for adults. If
drilling. The assistant is not sterile during the desired, the spacer can be used as a guide. The stylet
procedure although he/she is required to put on provided in the kit is inserted through the bolt and
sterile gloves to help the surgeon in the surgical dura to clear the passage for the transducer-tipped
(draped) field. catheter. Screwing in the skull bolt at an angle may
result in a fracture of the device. The stylet is then
Skin incision removed after the bolt has been screwed in, after
The skin and subcutaneous tissues should be incised which the bolt should be filled with saline. It may
(antero-posterior for roughly 2–3 cm in length) be important to check if CSF leaks out of the bolt
until reaching the periosteum. After the incision and, if so, at what pressure.
and retraction of the skin and subcutaneous tissue,
the periosteum should be scraped off with an Zeroing the catheter transducer tip
appropriate tool in order expose the skull. The most commonly used ICP monitoring devices
are provided with catheters that have the transducer
1. Divaricate with the mosquito forceps.
at one extremity (must remain sterile), and the
2. Select the appropriate drill bit. Use the 2.7 mm
socket that is to be attached to the monitor itself at
drill bit for subdural, intraparenchymal and bolt
the other. The zeroing is performed by simply
procedures (the 5.8 mm drill bit for ventricu-
holding the transducer tip in air zeroing on the
lostomy procedures).
monitor, after which the transducer is inserted
3. Place the drill bit into the chuck.
inside the bolt and the screw tightened. The ICP
While holding the drill handle in place, tighten value can then be read. Again, it is important to
the drill bit by turning the chuck anticlockwise. note the first ICP reading after the catheter is

r 2008 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 25 (Suppl 42): 192–195
 Intracranial pressure monitoring 195

Figure 2.
Drilling procedure.

inserted. A few seconds may be necessary until this some reports they were less in % than those
first value can be read with accuracy. encountered when inserting a central venous line.
The most clinically relevant complications were
Dressing meningitis, local infection, intracranial haematoma
After the bolt is secured in place, the intracranial and device failure.
pressure bolt site is covered with a sterile Kerlex
and the patient is observed in the ICU so as to avoid References
accidental pulling of the bolt.
Bleeding may occur at the site of the drill hole, 1. Bochicchio M, Latronico N, Zappa S. Bedside burr hole
originating from the scalp, bone, dural or cerebral for intracranial pressure monitoring performed by inten-
sive care physicians. A 5-year experience. Intensive Care
areas.
Med 1996; 22: 1070–1074.
2. Harris CH, Smith RS, Helmer SD. Placement of
Precautions intracranial pressure monitors by non-neurosurgeons. Am
It is essential to maintain strict aseptic technique Surg 2002; 68: 787–790.
during craniotomy procedures. Care should be 3. Ko KM, Conforti A. Training protocol for intracranial
exercised when applying sutures to ventricular pressure monitor placement by non neurosurgeons: 5-Year
catheters and over-tightening of bolt screws could experience. J Trauma Injury Infect Crit Care 2003; 55:
result in catheter occlusion or breakage. 480–483.
4. Latronico N, Marino R, Rasulo FA, Stefini R, Schembari
M, Chandiani A. Bedside burr hole for intracranial
Complications pressure monitoring performed by anaesthetist intensive-
As mentioned previously, in the literature compli- care physicians: extending the practice to the entire team.
cations have been found to be extremely rare, and in Minerva Anestesiol 2003; 69: 159–168.

r 2008 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 25 (Suppl 42): 192–195