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Importance of ICP monitoring in the investigation of CSF circulation disorders

The diagnosis and management of cerebrospinal fluid (CSF) circulation disorders is enhanced with our ability to identify pathological CSF dynamics and to measure cerebrospinal compensatory parameters. These features and measures may be obtained from CSF pressure monitoring and infusion studies. However, many clinicians still rely on the use of single CSF pressure measurements obtained from lumbar puncture (LP). A 69-year-old man was admitted to another hospital for management of dehydration secondary to severe vomiting. He had a 6-month history of progressive cognitive impairment, decreasing mobility and urinary incontinence. On examination he was noted to be drowsy and was unable to stand unaided. Fundoscopy revealed chronic papilloedema. A head CT was reported as showing cerebral atrophy and hydrocephalus. CSF opening pressure on lumbar puncture was 40 cmH2O. Other investigations were normal. He was transferred to this hospital for further assessment and intervention. On admission, clinical examination revealed poor mental performance (4/10 on MMST). The cranial FIG. 1. Axial T2-weighted magnetic resonance image. FIG. 2. Results of CSF pressure monitoring and lumbar infusion study. The CSF pressure, amplitude of the CSF pulse, the pressure-amplitude co-efficient (RAP) and heart rate (HR) are shown. The first two vasogenic waves began and ceased spontaneously. After a short period of stable baseline CSF pressure an infusion study was attempted at an infusion rate of 1 mL/min (arrow). However the CSF pressure began to rise rapidly and the infusion was ceased.