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LETTER TO EDITOR Table of Contents  
Ahead of print publication
The posterior fossa intracranial pressure monitoring in neurocritical care: It is time to evaluate objectively in forbidden territories

1 Department of Critical Care Medicine, Physician Regional Medical Center, Naples, FL, USA
2 Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia

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Date of Submission19-Jun-2022
Date of Acceptance25-Jun-2022
Date of Web Publication18-Oct-2022

How to cite this URL:
Janjua T, Moscote-Salazar LR, Florez-Perdomo WA. The posterior fossa intracranial pressure monitoring in neurocritical care: It is time to evaluate objectively in forbidden territories. Indian J Med Spec [Epub ahead of print] [cited 2023 Feb 1]. Available from: http://www.ijms.in/preprintarticle.asp?id=358780

Dear Editor,

Intracranial pressure (ICP) monitoring is considered to be one of the basic aspects of neurocritical practice. It can be a point-of-care evaluation with transcranial Doppler or optic nerve ultrasound. The most common approach is through the fluid column with cerebrospinal fluid. This can be continuous or intermittent. Pressure transduction can be done without direct contact with cerebrospinal fluid. These are devices with either fiberoptic, air, or string gauge technology.

The practice to follow ICP is exclusively in the supratentorial section with some practices using lumbar drain also. Due to tentorium cerebelli, it is not clear if the pressure from the posterior fossa will transmit back via the aqueduct to the catheter or the probe placed in the brain parenchyma. Conventionally, lesions in the posterior fossa are decompressed with ICP checks from the supratentorial location. The thought is to prevent herniation and close monitoring. There is always a risk of reverse herniation with superior decompression with normal supratentorial compartment due to the closure of the aqueduct. The pathophysiological knowledge of ICP and its variations in the different compartments is necessary to obtain the maximum benefits in the management.[1]

The placement of fluid drain into the posterior fossa is not possible, unlike the lateral ventricle. The remaining bone of the occipital bone can be used to place a probe to watch for posterior fossa pressure. This pressure can be compared to the supratentorial pressure to guide the optimum therapy. Khan et al. have shown in a case with posterior fossa herniation with normal supratentorial pressure. An ICP probe was placed for the management.[2] With the experience and knowing the transverse sinus anatomy, it is possible to place a probe through the occipital bone in the intensive unit to watch for the posterior fossa pressure. A cadaveric study showed that the extracranial point for insertion of the probe is at the retroauricular area, 2 cm behind the tip of the mastoid process and 2 cm below the transverse sinus.[3] The pooled data have shown significantly higher infratentorial ICP as compared to supratentorial pressure.[4]

In conclusion, posterior fossa pressure can be different in cranial pathologies. Checking only the supratentorial pressure may not give the full picture of the posterior fossa. It is possible to safely place a probe in the posterior fossa either under direct view during surgery or in the intensive care unit with a proper understanding of the anatomy and experience.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Rodríguez-Boto G, Rivero-Garvía M, Gutiérrez-González R, Márquez-Rivas J. Basic concepts about brain pathophysiology and intracranial pressure monitoring. Neurologia 2015;30:16-22.  Back to cited text no. 1
Khan A, Borg N, Shenouda E. Posterior fossa ICP monitoring: a tale of two compartments. Br J Neurosurg 2021;35:129-32.  Back to cited text no. 2
Vanaclocha V, Sáiz-Sapena N, Rivera-Paz M, Herrera JM, Ortiz-Criado JM, Verdu-López F, et al. Can we safely monitor posterior fossa intracranial pressure? A cadaveric study. Br J Neurosurg 2017;31:557-63.  Back to cited text no. 3
Won SY, Dubinski D, Hagemeier J, Behmanesh B, Trnovec S, Bernstock JD, et al. Intracranial pressure monitoring in posterior fossa lesions-Systematic review and meta-analysis. Neurosurg Rev 2022;45:1933-9.  Back to cited text no. 4

Correspondence Address:
Luis Rafael Moscote-Salazar,
Colombian Clinical Research Group in Neurocritical Care, Bogota
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_72_22


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