ANESTHESIA . . . Current Researches VOL. 54,N O . 5, SEPT.-OCT.

,
AND ANALGESIA 1975 687

Increased Cerebrospinal Fluid Pressure During Laryngoscopy

and lntubation for Induction of Anesthesia
ROBERT G. BURNEY, M.D.*
RICHARD WINN, M . D . t
Charlottesville, Virginia$

lntracranial pressure (ICP) was recorded
in 12 patients undergoing craniotomy and 2
patients for carotid arteriogram. ICP did not
change in response to the injection of contrast
medium but rose significantly and dramati-
cally in response to laryngoscopy and intuba-
tion. The increase appeared related to initial
ICP and thus may represent exhaustion of
compensatory mechanisms in these patients.
Special attention must be given to this factor
during manipulation of the larynx in neurosur-
gical patients with raised initial ICP or space-
occupying intracranial lesions.

D IVERSE factors can induce changes in

intracranial cerebrospinal fluid pres-
sure (ICP) : Cerebral blood flow (CBF),
jugular venous pressure, body position, in-
trathoracic pressure, intracranial pathology,
and drugs, including those used for anes-
thesia. Regardless of etiology, the pressure
can cause problems (for example, herniation
of brain tissue, cerebral ischemia) 132 and
must be carefully controlled during anes-
thesia for neurosurgery.
Monitoring of ICP with a subarachnoid
pressure screw (fig 1) has become routine
clinical practice in selected neurosurgical
patients.3 This screw can be inserted in a
few minutes under local anesthesia and pro- FIG 1. Pressure screw used in study, adapted
from one originally developed by Vries et al.3
vides valuable and reliable data.
Previous studies have shown that most
anesthetic agents tend to increase ICP.4-G METHODS
Our specific interest in this study was to Subjects were 14 patients in whom a sub-
determine the effects of events at the begin- arachnoid pressure screw had been inserted
ning of anesthesia (induction, laryngoscopy, through a burr hole under local anesthesia
and intubation) on ICP. prior to surgery (usually the day before).

"Assistant Professor of Anesthesiology.

+Fellow in Physiology and Neurosurgery.
$Departments of Anesthesiology and Neurosurgery, University of Virginia Medical Center, Charlottes-
ville, Virginia 22901.
Read at the 49th Congress of the International Anesthesia Research Society, March 16-20, 1975, Holly-
wood, Florida.
Paper received: 3/17/75
Accepted for publication: 5/20/75
688 ANESTHESIA
AND ANALGESIA ..
. Current Researches VOL.54,No. 5, SEPT.-OCT.,1975
TABLE
Changes in ICP and Time From
Laryngoscopy to Peak Pressure for
Craniotomy Patients Under General
Anesthesia
Starting Peak
pressure, pressure. Time to peak
Patient Diagnosis cm/HnO cm/HzO ICP, rec

1 Tumor 10 18 40
t------l 4 4 4
1 min. 1 T V
2 Tumor 14 32 30 FIG 2. Typical responses of ICP to laryngoscopy
3 Tumor 18 >40 4 5 (L), intubation (T), and mechanical hyperventila-
tion ( V ) in patient #3 (table).
4 Aneurysm 20 >60 125
5 Tumor 7 20 30
6 Tumor 10 18 50
7 Aneurysm 14 38 20
8 Tumor 10 22 ?
9 Tumor 20 35 47
€ 1
U

-
10 Aneurysm 8 17 ? 0
11 Tumor 20 32 63
12 Tumor 21 32 ?
.f.f
L T
1 mm.
Pressures were recorded on a Grass poly-
graph using a Statham pressure transducer FIG3. Typical responses in patient #2. Symbols
as in figure 2.
(P23 Bb) . Zero pressure reference level
was set at the external auditory canal (most
cases) or at the pressure-screw opening.
The technic for induction of anesthesia
varied somewhat with the individual anes-
thesiologists, but consisted basically of IV
thiopental, 0, by mask, IV succinylcholine,
manual hyperventilation, laryngoscopy, and
intubation. This was followed by mechani-
cal hyperventilation. NzO, with or without
enflurane, was used for maintenance of an-
esthesia, and pancuronium was used in
every case. In most cases, 1 mg of pancu- 0
1 I
5
I
10
I
I5
I
20
I
15

ronium had been given prior to the succinyl- STARTING PRESSURE (cm/H,O)

choline. Satisfactory records were obtained FIG 4. Maximum change in ICP in response to
in 12 patients undergoing craniotomy (ta- laryngoscopy and intubation, plotted against initial
ble). ICP.

In addition, 2 patients were monitored scopy and intubation was seen in every
during repeated injections (8 to 10 ml of case (table).
dye was injected at 8 ml/sec) of contrast
material for cerebral arteriograms, using Peak pressure was significantly different
local anesthesia only. from preinduction pressure at the 0.001 lev-
el, using a paired t-test. The magnitude of
the pressure change was not related to the
RESULTS diagnosis but seemed larger with a higher
Typical tracings obtained during the be- initial ICP before induction (fig 4). The
ginning of anesthesia are shown in figures 2 correlation coefficient (r2) for a linear plot
and 3. Diagnoses included brain tumor ( 6 ) , of the data in figure 4 is 0.22. The maximum
metastatic tumor (3), and intracranial rise in ICP occurred within 1 minute in
aneurysm ( 3 ) . A rise in I C P with laryngo- every case but one.
CSF Pressure During Intubation . . . Burney and Winn
ICP in the patients undergoing cerebral
arteriography did not change with the in-
jection of contrast material.
DISCUSSION
A rise in ICP coincident with laryngo-
scopy and intubation has been clearly shown
by this study. Shapiro's group7 also noted
this phenomenon and suggested thiopental
administration as a means of controlling
ICP rise. All our patients received thiopen-
tal (200 to 450 mg) within 3 minutes of
intubation. Although larger doses might
have reduced the magnitude of the ICP
rise,s the usual hypnotic doses did not pre-
vent it.
The Paco, undoubtedly rose because of
apnea during laryngoscopy and intubation.
However, it is doubtful if this factor alone
could account for the observed changes in
1cp.9
Jugular compression can increase ICP,
and the head was usually manipulated be-
fore laryngoscopy. However, care was tak-
en to avoid pressing on the neck; and, at
the time of laryngoscopy (maximum ICP
rise), there was no pressure on the outside
of the neck. It thus seems unlikely that ve-
nous obstruction contributed to the rise in
ICP.
Rich and coworkers10 have suggested that
changes in cerebrospinal fluid (CSF) pres-
sure are due to intracranial vascular changes.
Laryngoscopy and intubation are known to
produce tachycardia,ll hypertension,ll-l3
and sympathetic discharge.ll,l+ Chronic
systemic hypertension from a variety of
causes does not affect CBF.l"lG Yoshida
and associates8 observed a significantthough
transient increase in internal carotid flow
when hypertension was induced suddenly
by clamping the thoracic aorta. Thus, it
may be that CBF increased transiently in
our patients because the blood pressure
changed too rapidly for the autoregulatory
mechanisms. If the ICP changes reported
here are due to an increase in CBF result-
ing from systemic hypertension, this repre-
sents a failure of autoregulation.
Whatever the mechanism, these changes
in ICP are significant and may be hazard-
ous to some patients. If the rise in ICP
indeed results from the rise in arterial pres-
sure, topical anesthesia of the larynx, as
suggested by Denlinger's group12 may help
by reducing the pressor response. McLeskey
and colleagues* have advocated moderate
689
hyperventilation plus larger doses of thio-
pental (450 to 800 mg total) before laryn-
goscopy and intubation.
There was a tendency for patients with a
higher initial ICP to have a greater rise in
ICP during laryngoscopy (fig 4), although
the slope of a plot of these data was signifi-
cantly different from 0 only at the 0.1 level.
Since the actual pressure change depends
ultimately on the intracranial compliance
and the change in intracranial volume, a
perfect correlation would not be expected.
ICP is not a good measure of compliance,
and the change in intracranial volume pro-
duced by laryngoscopy would probably vary
widely in different patients. Nevertheless,
the data presented suggest that patients
with elevated initial pressure may be at
greater risk during laryngoscopy and intu-
bation.
The failure of the ICP to rise during in-
jection for cerebral arteriography was some-
what surprising in that the volume of dye
injected/sec represented a sizable propor-
tion of a patient's CBF. The stable ICP
presumably indicates that the dye replaced
the CBF during the brief period of injection
(1 sec) .
REFERENCES
1. Kindt GW, Waldman J, Kohl S, et al: Intra-
cranial pressure in Reye syndrome. JAMA 231:
822-825, 1975
2. Fitch W, McDowall DG: Hazards of anes-
thesia in patients with intracranial space-occupying
lesions. Int Anesth Clin 7:639-662, 1969
3. Vries JK, Becker DP, Young HF: A sub-
arachnoid screw for monitaring intracranial pressure.
J Neurosurg 39:416-419, 1973
4. Gardner AE, Olson BE, Lichtiger M: Cere-
brospinal fluid pressure during dissociative anes-
thesia with ketamine. Anesthesiology 35:226-228,
1971
5. Horsley JS: The ICP during barbital nar-
cosis. Lancet 232:141-143, 1937
6. Keats AS, Mithoefer JC: The mechanism of
inrreased ICP induced by morphine. New Eng J
Med 252:lllO-1113, 1955
7. Shapiro HM, Galindo A, Wyte SR, et al:
Acute intracranial hypertension during anesthetic
induction. Europ Neurol 8:118-121, 1972
8. McLeskey CH, Cullen BF, Kennedy RD,et
al: Control of cerebral perfusion pressure during
induction of anesthesia in high-risk neurosurgical
patients. Anesth & Analg 53:985-992, 1974
9. Yoshida K, Meyer JS, Sakamoto K, et al:
Autoregulation of cerebral blood flow: electromag-
netic flow measurements during acute hypertension
in the monkey. Circ Res 19:726-738, 1966
690 ANESTHESIA
AND ANALGESIA.
. Current Researches VOL.54, No. 5, SEPT.-OCT.,1975
10. Rich M, Scheinberg P, Belle MS: Relation-
ship between cerebrospinal fluid pressure changes
and cerebral blood flow. Circ Res 1:389-394, 1953
11. King BD, Harris LC J r , Greifenstein FE, et
al: Reflex circulatory responses to direct laryn-
goscopy and tracheal intubation performed during
general anesthesia. Anesthesiology 12:556-566, 1951
12. Denlinger J K , Ellison N, Ominsky AJ:
Effects of intratracheal lidocaine on circulatory
responses to tracheal intubation. Anesthesiology 41:
409-412, 1974
13. Takki S, Tammisto T, Nikki P, e t al: Effect
of laryngoscopy and intubation on plasma catechola-
mine levels during intravenous induction of anaes-
thesia. Brit J Anaesth 44:1323-1328, 1972
14. Tomori Z , Widdicombe JG: M u s c u l a r ,
hronchomotor, and cardiovascular reflexes elicited
by mechanical stimulation of the respiratory tract.
J Physiol (Lond) 200:25-49, 1969
15. Kety SS, Hafkenshiel JH, Jesters WA, e t al:
Blood flow, vascular resistance, and oxygen con-
sumption of brain in essential hypertension. J Clin
Invest 27:511-514, 1948
16. King BD, Sokoloff L, Wechsler RL: Effects
of I-epinephrine and 1-nor-epinephrine upon cerebral
circulation and metabolism in man. J Cliri Invest
31:273-279, 1952
G uest Discussion
JOHN K. VRIES, M.D.
Division of Neurosurgery
Medical College of Virginia
Richmond, Virginia
This paper provides further documenta-
tion of the marked alterations which occur
in intracranial dynamics upon induction of
anesthesia. The degree of rise in the ICP
reported with laryngoscopy and intubation
correlated well with the initial level of ICP.
This probably represents compromise of
.
the spatial buffering system, as suggested
by the authors. I suspect an even closer
correlation could be obtained if the rise in
ICP were correlated with the intracranial
compliance. This parameter can be calcu-
lated by observing the rise in ICP produced
by the injection of a small amount of saline
solution into the ICP m0nitor.l The dangers
of neuroanesthesia are largely a function of
this parameter.
At the Medical College of Virginia, we
routinely monitor patients with suspected
mass lesions in the preoperative period and
during the induction of anesthesia.”3 In pa-
tients with mild to moderate abnormalities
in intracranial compliance we have been
successful, by using hyperventilation, large
doses of thiopental, and topical laryngeal
anesthesia, in preventing marked rises in
ICP during induction. In patients with se-
vere abnormalities in intracranial compli-
ance we have maintained control of the ICP
by administering 1 gm/kg of mannitol 15
minutes before the induction of anesthesia.
It is apparent, however, that a wide variety
of anesthetic technics can be employed with
good results if proper consideration is given
to intracranial dynamics.
REFERENCES
1. Miller JD, Garibi J , Pickard J D : The effects
of induced changes of cerebrospinal fluid volume
during continuous monitoring of ventricular pressure.
Arch Neurol 28: 265-269, 1973
2. Becker DP, Young HF, Vries JF: Monitoring
in patients with brain tumors. Clin Neurosurg (in
press)
3. Vries J K , Becker DP: The equipment of the
intensive care unit. Clin Neurosurg (in press)

The chief worries of life arise from the foolish habit of looking before and after,
the petty annoyances, the real and fancied slights, the trivial mistakes, the sins, the
sorrows, even the joys. Bury them deep in the oblivion of each night.
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spection, the mistakes of yesterday paralyzing the efforts of today. To look back,
except on rare occasions for stock taking, is to risk the fate of Lot’s wife. The load
of tomorrow, added to that of yesterday, carried today, makes even the strongest falter.
-Sir Wm. Osler