2A I+ MIM 1992F+=A P7123, The Effect of Head Elevation on Intracranial Pressure in Intracranial Hypertension SSHU-TSENG LEE and JY1-FENG CHEN sasTRACT To understand the effet of heed elevation on increased intracranial pres sure, studies were performed in 22 patents with cerebral edema due to head Jnr. Intracranial pressure was measured withthe patient in four diferent positions: heed at O degree, esd elevate 20 degrees, 45 degrees and 60 degrees, without turing the head. intracranial pressure results were a follows: at 0 degree, 2478 150 (mean +SE) mm: head elevate 30 degrees, 23 (64£2.40 mig: heed elevate 45 segres, 18.14 1.2 mmHg: head elevate 60 ciegroes, 1718+ 1.70 mn. Intracranil pressures were lower inal head ole vate poston but only head elevate 45 degrees or 60 degrees reach the stats al significance (P< 0001). The dota suggest thatthe head elevate 45 degrees or 60 degrees have a greatr chance 10 reduce the inreased intracranial res sure in patients with intracranial hypertension. The elevation of head to 45 learoes or 60 degrees might be the frst simplest treatment to intracranial ypertension ‘ey words Head elevation, intracranial hypertensin, intracranial pressure. Control of increased intracranial pressure on patent with normal intracranial pressure, remains a major challenge inthe management of neurological and neurosurgical patents. Oe ofthe simplest way has boon th patients’ head wich Is presumed to redice cerebral venous pressure or and hence ICP. Many peevous reports notes that moving 0 patient fam the supine to siting position causes Signicant reduction of intracranial pres: sure", but most studies were performed vation of Deparinent of Neorosiraery Taps Muri Chang it Host Tape Taina, 80. after craniotomy. In order to determine te opt mal bead poston fr patients wth raise intra cravial pressure we studied the eect of several head positions onitracraial pressure by using the subarachnoid serew to monitor ICP continu- sy, tie ey‘Shih Teeng Lee and Jyi-Feng Chen MATERIAL AND METHOD ‘This study was performed in 22 patents with cerebral edema cause by head inary wi cut intracranial hemetoma. Tho groups const fo of 15 mals and 7 females, ranging in age {rom 21 063 years with a mean of 32.54 yes (able |). All patents were admitted to the intensive care unt with fora subaracois screw for eantinsous monitoring of intracranial pressure, The subarachaold Screw was oo nected by a starie cathter(Cobe Laboratories Ine, Lakewood, Cola) to 2 transducer (Hevlett Packard, Andover, Mass). The pressure tas: tcer was clorates and kopt at he lve the patient's foramen of Meno foreach presire recarding, A contnouous digital spay of mean Intracranial pressure was oblaned. The folow ing postions were studied: supine with bed at the horizontal setting (0 degree), supine wth head ofthe bed up 30 degrees, up 45 dees Table |, Summary of Demographic Features of 22 ationts| at ‘ae (years) ange 21.36 Moan =SeM 3254286 sex Mate 5 Female 1 coma Seale ® 6 7 7 6 5 5 3 4 ' cause of Inu Motorcycle “ cer 5 Pedestrian 3 and up 60 cegroes. The neck of pationts was maintained in al postions to prevent jugular vein compression. Intracranial pressure mea surements for each position were taken every 10 seconds fo | rind ater a5 minute stable tion period, The mean of intracranial pressure measurements was used for statistical compari+ sons between the four groups. Students test ‘nas used for stati! significance inthe data interpretation. RESULTS ach position was compared withthe ston dard ead postion, of sunne, 0 degrees elev tion. The mean intracranial pressure for each postion compared to the mean intracranial pressure at 0 degree postion, 2473:1.50 (rnean:SEW) mg, ad statistical significance of the eifrence determined, For the group as 2 whole, the intraeranial pressures were de creased after elation of the head (Fi 0: head elevated 30 degrees, 2268:2.6 mmHe (P0105), head elevate 45 degrees, 19.141 52 mmig (P< 00), and head elevated 60 degrees, 17,181.70 mm He (P<0.001), How- ever, some patents had a diferent changes Seven ptiants with 30 degrees head u, three ations wth heed up 45 degrees, and two patients with hexd up 60 degrees showed in reas intracr their own stancaré poston (Fig. 24). The change in mean intracranial pressure from supine 0 degree to the diferent elevated posi tions were as flows: head up 30 degrees, 1! rm He, head up 45 degrees, 56 mtg and head up 60 degries 7.2 mmHg a pressure 38 compared withThe Ect of Head Elevation om Intracranial Pressure in Intracranial Hypertension + SE i: seas" N=22 F005 P001 Peat Fle 1. ets of eatin on nacre shad 0 dees 50° ead UO press A Sines 3 i s- f i. a i 3 i = eating 100 ot and bed wp 2° 2 Fase ate t Fg. Indvval response of 2 patients’ natal pressre onchange sostion fom O degrees to head upShik-Teeng Lee and Jyi-Feng Chen e sing 1g gt fon tt a in Ge E iso a. Fr. 3. Inbal esponseof 2 patients intracranial pressure on chang poston tom 0 erees tone a| = scisa? - esting 17 ot OF end ad op 1 in 22 HI orien Gane No wh7. WE 70 P0.00 Fg 4 India! sponse of 2 patients’ intracranial pressure on charg postn fom 0 degrees a hea 0 aeveos,DiscussioN. Many wel known factors contbute to intra Cranial hypertension in head injury patients, sich 95 development of intracranial. mass lesions, change of blood pressure, intemal Iugula vin compression due to malpsition pos iv pressure ventilation, dsplacement of CSF etc". Allof these would be expected to have a reduction of intracranial pressure after eleva tion of the head. For patients without intra Cranial pathology the head up postion may lower intracranial pressure ue to caudal move mont of cerebrospinal id”. Kennig et al” have demonstrated hatin he siting or semis ting poston the inraranal prssure. wil marked imiish inpatients with intracranial bypertension but the sting position is rather Gitcat to maintain fora long period of time uring the care of prolong comatous patents In cour resus for patients as @ whole head up 30 grees oly a slight decrease in intracranial Dressure was observed, but Read up &5 ogre (oF 60 degrees showed sintcant reduce of Intracranial pressure in patents with intra cranial hypertension as was found in other studies"“®, The possible mechanism may be thatthe further the head is elevate the more tional drainage of cerebrospinal fd and cerebral venous low causing more dedi in Intracranial pressure a=. indicated by the Monro elie doctrine. Ropper et al." proposed that brain tissue shit toward the foramen magrum impading CSF ution may raise rather than reduce intra cranial pressure asthe head is elevated. There aro several studies dernonstating tat in with normal condtion when the patie is sting or pees ‘The Elfct of Head Elevation on Intracranial Pressure in Intracranial Hypertension Semisiting the dural sinus pressures are reduced to negative values", but those studies were performed with patients without ‘otra cranial hypertension and with some extent of raniectomy and without concomitant measur iment of intracranial pressure, twabuch et a” sso noted that jugular bulb pressure did not always rflct the dura confluences sins pres: sure, Increased intracranial pressure may cause secondary compression to the basal dural Sinuses. fhe elevation of the head causes 2 caudal sit ofthe intseranilcontant and com: pressed of the basal dural sinuses it may cause further venous stasis and henen an increase in Intracranial oressure, Whether ineeased intra cranial pressure wil cause secondary basal ‘ural sinuses compression ater head elevation needs further study [though ia general, the rest from our study suggested Io patonts with intracranial hypertension head up &5 degrees or 60 degrees Is etter than head up 30 degrees in reduce intracranial pressure, iniviual responses were variable ‘The authors recommend elevation of the oad to 45 degrees or 60 degrees a8 fist sim ple treatment of intracranial hypertension. Con: tinwe monitoring of intracranial pressure is of seat importance because individual response to head elevation vary When intracranial pressure monitoring isnot avaiable, head up 45 degrees or 60 depres is suggestd REFERENCES | Toole JF: Etets of change of he, lib, and body postin on cephalic relation. N ng! J Mod 278; 30731, 1968 a ine ete‘Shih Taeng Lee and Joi Feng Chen influencing intracranial pressure, Anesth ing postoning of severe head nury siology 26; 31.1971 patients, Haart & Lang 18 411-414, 1988, 3. Shapiro HM: Intracranial hypertension: 7, Magnaes 8: Movement of cerebrospinal therapeutic and anasthtic considerations. tid witha the eanosponal space when Anesthesiology 83; 445-471, 1975. siting up on ving down. Surg Neurol 10; 4. Yoneda, Matsuda M, Manda J, ea: Con 15.49, 1978 tinuous measurement of intacraial pres: 8. Rooper A, ORouche D, Kennedy Sk: Head sure with SFT: cineal experiance. Surg poston, tracranial pressure ané coma Neurol 4; 289.285, 1995. ance, Neurology 32; 1288-1281, 1982. 5. Kennig JA, Joutat SM, Saunders RL: 9. Iwabuchi T, Sobata E, Suzuki M, etal print patent positioning inthe manage Dural sius pressure as related to nour rent of intracranial hypertension. Surg surgical postos. Newrosurgory 12; 203+ Neurol 15; 148-182, 1981. 207,18 6, Lee ST: Intocranial pressure changes dur Adress for Reprints: SHIH-TSENG LEE M.D. Department of Neurosurgery Tape! 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