INTRACRANIAL DYNAMICS IN THE

SUPINE AND STANDING POSITIONS:

DOES ANYTHING MORE CHANGE
THAN THE MEAN INTRACRANIAL
PRESSURE?
Patricia López Gómez
Idoia Valduvieco Juaristi, Ignacio Pinto Rafael
Guillermo García Catalán, Jesús Esteban García, Carlos Bucheli
Rubén Martín Laéz
Introduction

•Little is known about variation in

dynamics of CSF when non-critically ill
patients change from supine to standing
position
•First article by Loman published more
than 80 years ago (1934).
Introduction

Cisternal pressure gradient: 12 mmHg Lumbar pressure gradient: 25 mmHg

Introduction

•Next study by Magnaes 40 years later.

•Lumbar CSF pressure: 72 patients with
spondylosis
Introduction

•Lumbar pressure rise with de

sitting position
•Limitations: no numeric data
Introduction

•Andersen et al (2014)
•4 adult patients scheduled for complete
removal of a solitary, clearly demarcated,
small brain tumor
Introduction

Gradient ICP
5,6 mmHg

Gradient ICP
4,2 mmHg
Introduction

Petersen (2015)
9 ambulatory patients
Introduction

ICP gradient: 14,3 mmHg

 Introduction

But the ICP is not just a number…

What happens with other parameters

such as the RAP index, dPdt ...?
Material & Methods

Patients admitted to our CSF dynamics

unit that underwent ICP monitoring.

Codman microICP intraparenchymal

sensor.

Raw ICP data was automatically analyzed

using ICP Digital Tools®
Material & Methods

ICP MONITORING
Material & Methods

Descriptive statistics

Mean ICP
Dispersion
Material & Methods

ICP Pulse pressure

dP/dt
Material & Methods

RAP INDEX: Pearson correlation coefficient between

PP and mean ICP.

PP = RPPC * PIC + P0

RPPC: lineal regresion coefficient between PP and

mean ICP

P0: the pressure at which the elastance equals

zero.
 Material & Methods

Retrospective review of patients that underwent computerized ICP monitoring

Inclusion criteria
a) Normal quantitative and qualitative nocturnal ICP recording and hydrodynamics
PIC < 12 mmHg
dPdt < 25 mmHg
PP < 5 mmHg
RAP index < 0,600

b) Normal CSF hydrodynamics

Rout < 12 mmHg
PVI = 15 – 30 ml
Material & Methods

Recording of at least 30 minutes before

and after a postural change from
decubitus to standing.

Poca et al. Posture-induced changes in intracranial pressure. Neurosurgery. 2006.

 Material & Methods

Retrospective review of patients that underwent computerized ICP monitoring

Exclusion criteria
a) Abnormal ICP recording
b) Shunted patients
c) Image findings on MRI other than ventricular enlargement
Materials and methods
PATIENTS
PATIENTS RECORDED
(n=308)

NO monitoring
during postural
changes (n=91)

Monitoring during
postural changes
(n=217)

Abnormal ICP
monitoring or MRI
alterations (n=186)

Normal ICP monitoring

(n=31)
Materials and methods

STATISTICS

SPSS v.21 © (IBM)

-P<0,05
-Student’s t test paired, for mean comparison.
-Wilcoxon signed-rank test, for median comparison
Results

PATIENTS

Age Height Weight BMI

Mean ± SD 65,90 ± 18,17 160,86 ± 9,19 70,31 ± 11,21 26,53 ± 3,54
Males
Male 68,29 ± 20,83 167,86 ± 5,46 79,80 ± 6,56 28,40 ± 2,62 45,16% (n=14)
Female 63,94 ± 16,05 157,36 ± 8,76 64,37 ± 9,26 25,59 ± 3,64 Females
P* 0,517 0,010 <0,001 0,086
54,84% (n=17)
Range 18 - 88 147 - 181 45 - 90 20,00 – 32,42
Male 18 - 88 160 – 177 70 - 90 25,71 – 32,42
Female 25 - 81 147 – 181 45 - 75 20,00 – 31,22 *Independent
Median 69 160 71 26,81 samples
Male 76 169 81 27,31 Student’s t test
Female 68 155 64 24,44
P** 0,138 0,003 <0,001 0,128
**Mann-
Interquartile range 63 - 78 153 - 167 62,75 - 78,50 23,71 – 29,69
Male 56 - 82 164 -170 73,75 – 84,25 26,03 – 31,14 Whitney U test
Female 64 - 72 150-163 56,25 – 73,50 22,87 – 28,52
Results

Supine Standing ∆ P
Mean ± σ 3,66 ± 3,17 -5,62 ± 3,63 -9,28 <0,001*
ICP
Median 4,09 -5,44 -9,53 <0,001**
Mean ± σ 1,79 ± 0,94 2,20 ± 0,98 0,41 0,008*
Dispersion
Median 1,62 1,94 0,32 <0,001** *Paired
Mean ± σ 2,74 ± 4,94 2,32 ± 4,06 -0,42 0,428* Student’s t test
Skewness
Median 0,76 0,74 -0,02 0,422**
Mean ± σ 78,06 ± 291,72 74,88 ± 291,64 -3,18 0,738* **Wilcoxon
Kurtosis
Median 4,66 1,73 -2,93 0,224**
Mean ± σ 2,88 ± 0,93 3,58 ± 1,24 0,70 <0,001*
signed-rank test
Pulse
pressure Median 2,81 3,51 0,70 <0,001**
Mean ± σ 15,15 ± 6,64 17,79 ± 7,17 2,64 0,006* No difference
dPdt
Median 13,88 17,24 3,36 0,009** between males
Mean ± σ 0,097 ± 0,297 0,161 ± 0,244 0,064 0,208*
RAP index and females
Median 0,051 0,191 0,14 0,281**
Mean ± σ 0,122 ± 0,387 0,140 ± 0,293 0,018 0,743*
RPPC
Median 0,073 0,143 0,07 0,422**
Mean ± σ -1,75 ± 13,60 -15,83 ± 10,15 -14,08 <0,001*
P0
Median -0,32 -13,53 -13,21 <0,001**
Results

Standing ICP
Standing ICP = 0,840 * Supine ICP – 8,832
Adjusted R2 = 0,395
(P <0,001)

Supine ICP
Results

∆ ICP = 0,050 * Age + 5,894

Adjusted R2 = 0,126
(P =0,039)
∆ ICP

Age
Results

Standing ICP Dispersion

Standing ICP Disp = 0,725 * Supine ICP Disp – 0,840
Adjusted R2 = 0,462 (P <0,001)

Supine ICP Dispersion

Results

Standing PP = 1,070 * Supine PP + 0,377

Adjusted R2 = 0,694
(P <0,001)

Standing Pulse Pressure

Supine Pulse Pressure
Results

∆ Pulse Pressure

∆ PP = 0,031 * Height - 5,712

Adjusted R2 = 0,295
(P = 0,030)

Height
Results

Standing dPdt
Standing dPdt = 0,901 * Supine dPdt + 3,718
Adjusted R2 = 0,625
(P <0,001)

Supine dPdt
Results

∆ dPdt

∆ dPdt = 0,223 * Height - 38,291

Adjusted R2 = 0,227
(P = 0,046)

Height
Results

No apparent relationship
between supine P0 and
standing P0
Results

∆ P0

∆ P0 = -0,190 * Weight + 24,173

Adjusted R2 = 0,190
(P = 0,046)

Weight
 Discusion
• Previous reports: Decreased ICP with sitting or standing position.

Andersen et al (2014) Petersen et al (2015)

4 patients 9 patients

ICP gradient: 5,6 mmHg (2 wks) and 4,2 mmHg (4 wks)

Discusion

33 critically ill patients of mixed ethiology

ICPPA increased with elevation of head
Discusion

This is the first study that tries to give a shed of light to the “normal”
pattern of ICP dynamics during postural changes.
When a subject adopts the standing position…

ICP
P0
ICP
dispersion
PP
dPdt

No statistically significant changes in other parameters.