Relationship between flexion of the neck and changes in intracranial pressure
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1 Relationship between flexion of the neck and changes in intracranial pressure Sarah Hornshoej, Alexander Lilja, Morten Andresen, Marianne Juhler Sarah Hornshoej Tel: Clinic of Neurosurgery, 2092 Mail: Rigshospitalet, Copenhagen Website:
2 Introduction Intracranial pressure (ICP) is strongly influenced by posture changes We observed that ICP decreased immediately when the neck was extended Other investigators have shown that ICP can vary with neck position ligation of the internal jugular vein (IJV) increases CSF pressure ipsilateral rotation of the head reduces blood flow in IJV Our observation led us to the hypothesis that the neck veins may be an important determinant in positional regulation of ICP Aims; Study I: To clarify to what extent flexion of the neck affects ICP in self- reliant patients Study II: To visualize patency of the internal jugular vein with body and head in different positions
3 Methods All patients, with a GCS score 14, undergoing postural change examination from February 2014 to March 2015 were included (n=45, 16 males, age range 10 to 81 years). A1 A2 B1 B2 d1a) straight neck 1b) neck flexion 2a) neck flexion 2b) straight neck Study I: A: the patient in upright sitting position with a straight back, and straight neck (A1) vs. maximal neck flexion (A2). B: the patient in sitting position as for a lumbar puncture with a flexed back and maximal neck flexion (B1) vs. straight neck (B2). Each position was maintained for ten minutes. Study II: The internal jugular vein was visualized by ultrasound with the patient in supine position and in the four vertical positions. For each scan the cross sectional area of the vein was measured.
4 Results, Study I; Correlation between neck posture and ICP Horizontal LP! Vertical Both pressure and amplitude can be read in the curve. The left panel shows the horizontal position, while the right panel shows the four vertical positions. B1 LP=lumbar puncture position A1 A2 B2 A1=Upright sitting, straight neck A2=Upright sitting, neck flexion B1=Sitting LP, neck flexion B2=Sitting LP, straight neck The figure illustrates the typical ICP changes in different body and head postures
5 Results, Study I; Correlation between neck posture and ICP ICP$[mmHg]$ 40$ 30$ In the upright sitting position: ICP$[mmHg]$ 40$ 30$ B1 In the sitting LP position: 20$ 10$ 0$!10$!20$ A1 A2 All patients presented an increase in ICP following neck flexion 20$ 10$ 0$!10$!20$ B2 All patients presented a decrease in ICP following neck extension!30$ Straight neck Neck flexion!30$ $ Neck flexion Straight neck n = 42, p < , CI95% = 7.3; 9.7 n = 38, p < , CI95% = ; Body posture Upright sitting Sitting LP Neck posture Straight Flexed Flexed Straight Median ICP [mmhg] Median ICP change after neck flexion [mmhg] 7.5 (range: 1.9 to 20.0) 15.9 (range: 4.5 to 24.3)
6 Results, Study II; Correlation between neck flexion and the IJV A1, Upright sitting, straight neck A2, Upright sitting, neck flexion B1, Sitting LP, neck flexion B2, Sitting LP, straight neck m " " " The patient is a 60 year- old woman with suspected normal pressure hydrocephalus, who underwent ICP monitoring to evaluate shunt function. The circumference of IJV is marked with blue. All patients presented a compression of the jugular vein following neck flexion Body posture Upright sitting Sitting LP Neck posture Straight Flexed Flexed Straight Median vein area [mm 2 ] Median intraperson variation in vein area after neck flexion [mm 2 ] 13 (n=9, p=0.008) 15 (n=9, p=0.008)
7 Conclusions Study I: In self- reliant patients we document that ICP increases in an upright sitting position with a flexed neck ICP decreases in response to neck extension in sitting lumbar puncture position Study II: We confirm the hypothesis that the change in ICP may be caused by compression of the internal jugular vein The results suggest how a small intervention can have profound implications on interpretation of ICP and on clinical decisions. A neutral head position can be used as a therapeutic tool to lower ICP Sarah Hornshoej Tel: Clinic of Neurosurgery, 2092 Mail: sh@cphcsf.dk Rigshospitalet, Copenhagen Website:
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