Head position affects intracranial pressure

in newborn infants *
 M.D. Janet R. Emery,
 M.D. Joyce L. Peabody

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DOI: 10.1016/S0022-3476(83)80728-8
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We studied the effects of six different head positions on intracranial pressure and cerebral
blood flow velocity in six infants with a recent history of asphyxia and eight without. ICP
was measured nominvasively using a transfontanel pressure transducer, and CBF was
assessed using the continuus-wave Doppler method. We found that ICP was lowest with the
head elevated and in the midline (P<0.01), and that ICP was higher in all infants in the
dependent position (P<0.001). This increase was significantly greater in those who had had
an episode of asphyxia during the 48 to 72 hours prior to the study (P<0.02). Therefore, we
recommend a head elevation of 30 degrees in the midline in any infant with increased ICP or
at high risk for cerebral injury, and caution against the use of the dependent position in these
infants.

Supported by Heart, Lung and Blood Institute Program Project Grant HL 24075,

National
Institutes of Health.
Reprint requests: Janet R. Emery, M.D., Children's Hospital and Cardiovascular
Research Institute, University of California, San Francisco, CA 94119.

Copyright © 1983 Published by Mosby, Inc.

http://www.sciencedirect.com/science/article/pii/S0022347683807288 (8-9-2014)
influence of body position on tissue-pO2, cerebral
perfusion pressure and intracranial pressure in
patients with acute brain injury
(PMID:9192375)

 Abstract

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Meixensberger J, Baunach S, Amschler J, Dings J, Roosen K

Department of Neurosurgery, University of Würzburg, Germany.
Neurological Research [1997, 19(3):249-253]
Type: Journal Article, Research Support, Non-U.S. Gov't
Abstract Highlight Terms
Genes/Proteins(3)
It is a common practice to position head-injured patients in bed with the head elevated above the level of the
heart in order to reduce intracranial pressure (ICP). This practice has been in vivid discussion since some
authors argue a horizontal body position will increase the cerebral perfusion pressure (CPP) and therefore
improve cerebral blood flow (CBF). However, ICP is generally significantly higher in the horizontal position.
The aim of this study was to evaluate changes in regional microcirculation using tissue pO2 (ti-pO2), as well as
changes in cerebral perfusion pressure (CPP) and intracranial pressure induced by changes in body position in
patients with head injury. The effect of 0 degree and 30 degrees head elevation on ti-pO2. CPP, ICP and arterial
blood pressure (MABP) was studied in 22 head injured patients during day 0-12 after trauma. The mean ICP
was significantly lower at 30 degrees head elevation than at 0 degree (14.1 + 8.6 vs. 19.9 + 8.3 mmHg). While
MABP was unaffected by head elevation, CPP was slightly higher at 30 degrees than at 0 degree (76.5 + 13.5
vs. 71.5 + 13.2 mmHg). However, regional ti-pO2 was unaffected by body position (30 degrees vs. 0 degree:
24.9 + 13.1 vs. 24.7 + 12.9 mmHg). In addition, there was no change in the time course after trauma concerning
these findings in the individual patients. The data indicate that a moderate head elevation of 30 degrees reduces
ICP without jeopardizing regional cerebral microcirculation as monitored using a polarographic ti-pO2
microcatheter.

http://europepmc.org/abstract/med/9192375 (8-9-2014)
Effects of neck position on intracranial
pressure
1. A Williams and
2. SM Coyne

Abstract

OBJECTIVE: To investigate the effects of four nonneutral neck positions on intracranial

pressure. DESIGN: An alternating treatment design was used to investigate the effect on
intracranial pressure of rotation of the head to the left and right, neck flexion and neck
extension. Each experimental position was separated by a neutral recovery period. SETTING:
Neurological intensive care units in two tertiary care centers in the southwestern United
States. SUBJECTS: Ten patients whose intracranial pressure was being therapeutically
monitored but who were not experiencing prolonged periods of elevated intracranial pressure.
PROCEDURE: Each neck position was maintained manually by the research staff for 5
minutes. Intracranial pressure was recorded at 1-minute intervals throughout the 45-minute
data collection period. RESULTS: Rotating the head to the right and left and placing the neck
in flexion resulted in significantly higher intracranial pressure readings than the baseline
neutral neck position or positioning the neck in extension. The highest individual intracranial
pressures always occurred with the head and neck rotated or in flexion. CONCLUSIONS:
These data support previous studies that indicated that a patient at risk for pathological
increase in intracranial pressure should not be positioned with the neck in flexion or the head
turned to either side.

Am J Crit Care January 1, 1993 vol. 2 no. 1 68-71

http://ajcc.aacnjournals.org/content/2/1/68.short
Upright patient positioning in the
management of intracranial hypertension
 James A. Kenning, M.D.,
 Steven M. Toutant, M.D.,
 Richard L. Saunders, M.D.

DOI: 10.1016/0090-3019(81)90037-9
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Abstract

Utilizing either a subarachnoid screw or an intraventricular cannula, intracranial pressure was

continuously monitored in 24 patients with established or potential neurological impairment
of various etiologies. Marked diminution in intracranial pressure was observed in the sitting
or semisitting position in the 13 patients with documented intracranial hypertension as well as
in the 11 in whom intracranial pressure was not elevated. This sustained effect was noted
even when superimposed on intensive medical management of intracranial hypertension.

Keywords

 intracranial pressure;
 postural changes;
 cerebrospinal fluid pressure;
 intracranial pressure monitoring

Address reprint requests to Dr. Richard L. Saunders.

Copyright © 1980 Published by Elsevier Inc.

http://www.sciencedirect.com/science/article/pii/0090301981900379
Journal of Neurosurgical Anesthesiology:

January 2000 - Volume 12 - Issue 1 - pp 10-14

Clinical Reports

Effects of ×Neck Position and Head Elevation on ×Intracranial Pressure in

Anaesthetized Neurosurgical Patients: Preliminary Results

Mavrocordatos, P.*; Bissonnette, B.‡; Ravussin, P.*†

Abstract

This study reports the collective effect of the positions of the operating table, head, and neck
on intracranial pressure (ICP) of 15 adult patients scheduled for elective intracerebral
surgery. Patients were anesthetized with propofol, fentanyl, and maintained with a propofol
infusion and fentanyl. Intracranial pressure was recorded following 20 minutes of
stabilization after induction at different table positions (neutral, 30° head up, 30° head down)
with the patient's neck either 1) straight in the axis of the body, 2) flexed, or 3) extended, and
in the five following head positions: a) head straight, b) head angled at 45° to the right, c)
head angled at 45° to the left, d) head rotated to the right, or e) head rotated the left. For
ethical reasons, only patients with ICP ≤ 20 mm Hg were included. Intracranial pressure
increased every time the head was in a nonneutral position. The most important and
statistically significant increases in ICP were recorded when the table was in a 30°
Trendelenburg position with the head straight or rotated to the right or left, or every time the
head was flexed and rotated to the right or left—whatever the position of the table was. These
observations suggest that patients with known compromised cerebral compliance would
benefit from monitoring ICP during positioning, if the use of a lumbar drainage is planed to
improve venous return, cerebral blood volume, ICP, and overall operating conditions.

© 2000 Lippincott Williams & Wilkins, Inc.

http://journals.lww.com/jnsa/Abstract/2000/01000/Effects_of_Neck_Position_and_Head_Elevation
_on.3.aspx
Neurosurgery:

March 2004 - Volume 54 - Issue 3 - pp 593-598

doi: 10.1227/01.NEU.0000108639.16783.39

Clinical Studies

Effects of ×Head Posture on Cerebral Hemodynamics: Its Influences on

Intracranial Pressure, Cerebral Perfusion Pressure, and Cerebral
Oxygenation

Ng, Ivan F.R.C.S.(SN); Lim, Joyce B.H.S.N.; Wong, Hwee Bee M.Sc.

Abstract

OBJECTIVE: Severely head-injured patients have traditionally been maintained in the head-
up position to ameliorate the effects of increased intracranial pressure (ICP). However, it has
been reported that the supine position may improve cerebral perfusion pressure (CPP) and
outcome. We sought to determine the impact of supine and 30 degrees semirecumbent
postures on cerebrovascular dynamics and global as well as regional cerebral oxygenation
within 24 hours of trauma.

METHODS: Patients with a closed head injury and a Glasgow Coma Scale score of 8 or less
were included in the study. On admission to the neurocritical care unit, a standardized
protocol aimed at minimizing secondary insults was instituted, and the influences of head
posture were evaluated after all acute necessary interventions had been performed. ICP, CPP,
mean arterial pressure, global cerebral oxygenation, and regional cerebral oxygenation were
noted at 0 and 30 degrees of head elevation.

RESULTS: We studied 38 patients with severe closed head injury. The median ×Glasgow
Coma Scale score was 7.0, and the mean age was 34.05 ± 16.02 years. ICP was significantly
lower at 30 degrees than at 0 degrees of head elevation (P = 0.0005). Mean arterial pressure
remained relatively unchanged. CPP was slightly but not significantly higher at 30 degrees
than at 0 degrees (P = 0.412). However, global venous cerebral oxygenation and regional
cerebral oxygenation were not affected significantly by head elevation. All global venous
cerebral oxygenation values were above the critical threshold for ischemia at 0 and 30
degrees.

CONCLUSION: Routine nursing of patients with severe head injury at 30 degrees of head
elevation within 24 hours after trauma leads to a consistent reduction of ICP (statistically
significant) and an improvement in CPP (although not statistically significant) without
concomitant deleterious changes in cerebral oxygenation.

Copyright © by the ×Congress of Neurological Surgeons

http://journals.lww.com/neurosurgery/Abstract/2004/03000/Effects_of_Head_Posture_on_Ce
rebral_Hemodynamics_.20.aspx