INTRACRANIAL DYNAMICS IN THE SUPINE AND

STANDING POSITIONS: DIFFERENCES BETWEEN

SECONDARY HYDROCEPHALUS, IDIOPATIC
NORMAL PRESSURE HYDROCEPHALUS,
PSEUDOTUMOR CEREBRI AND CHIARI
MALFORMATION.
Patricia López Gómez (R2 NCR-URQ)
Idoia Válduvieco Juaristi, Ignacio Pinto Rafael (FEA NCR-URQ)
Guillermo García Catalán, Jesus Esteban García(NCR-URQ)
Ruben Martín Laéz (Jefe Servicio NCR-URQ)
INTRODUCTION

376 patients
207 NPH
53 Chiari Type I
44 Chiari Type II
11 Pseudotumor
20 Aqueductal stenosis
41 Other
INTRODUCTION

• ICP fell when adopting sitting

position in all patients
• The decrease was lower in Chiari
patients
 INTRODUCTION

Andersen (2015)
31 patients
7 IIH
2 NPH
18 other forms of hydrocephalus
INTRODUCTION

We see marked posture-related changes in ICP, but no difference is seen between

patient groups in the measured body postures.
INTRODUCTION

Differences between the normal group and the patient groups stand
out, with normals maintaining a narrower interval of ICP across body
postures.

Normal patients were different from patients with normal pressure

hydrocephalus in their ability to maintain postural ICP stability
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
• Recording of at least 30 minutes before and after a postural change from decubitus to standing.

Exclusion criteria
• Normal quantitative and qualitative nocturnal ICP recording and hydrodynamics
• Shunted patients
MATERIAL & METHODS
PATIENTS
RECORDED
(n=308)
NO monitoring
during psotural
changes (n=91)

Monitoring during
postural changes
(n=217)

Normal ICP
monitoring
(n=31)

Miscelaneus Abnormal ICP monitoring

(n=28) or MRI alterations (n=186)

Secondary Chiari
Pseudotumor
iNPH (n=99) Hydrocephalus malformation
cerebrii (n=8)
(n=28) (n=27)
RESULTS

iNPH Controls
P
(n=99) (n=31)
Male/Female ratio 1,538 0,823 0,191
Age 74,79 ± 6,74 65,90 ± 18,17 0,012
Height
Weight
163,67 ± 7,76
77,80 ± 12,06
160,86 ± 9,19
70,31 ± 11,21
0,160
0,006
iNPH patients
BMI 29,02 ± 3,80 26,53 ± 3,54 0,008 • 60 males and 39 females
Supine 6,28 ± 3,87 3,66 ± 3,17 0,001
ICP Standing -3,17 ± 3,56 -5,62 ± 3,63 0,001
∆ -9,45 ± 2,32 -9,28 ± 2,90 0,740
Supine 2,78 ± 1,09 1,79 ± 0,94 <0,001
ICP
Standing 2,83 ± 1,02 2,20 ± 0,98 0,003
Dispersion
∆
Supine
0,05 ± 1,07
4,97 ± 1,94
0,41 ± 0,80
2,88 ± 0,93
0,050
<0,001
Differences with the control group:
Pulse
pressure
Standing 5,33 ± 1,92 3,58 ± 1,24 <0,001 • Age
∆ 0,36 ± 1,22 0,70 ± 0,75 0,071
Supine 21,51 ± 9,44 15,15 ± 6,64 0,001 • Weight
dPdt Standing 23,43 ± 8,43 17,79 ± 7,17 0,001
∆ 1,91 ± 6,35 2,64 ± 4,96 0,562 • BMI
Supine 0,248 ± 0,309 0,097 ± 0,297 0,017
RAP index Standing 0,235 ± 0,287 0,161 ± 0,244 0,201
∆ -0,013 ± 0,279 0,064 ± 0,279 0,178
Supine -7,03 ± 15,21 -1,75 ± 13,60 0,049
P0 Standing -16,91 ± 10,67 -15,83 ± 10,15 0,625
∆ -9,88 ± 14,78 -14,08 ± 3,48 0,206
RESULTS

Supine Standing P ∆
Mean ± σ 6,28 ± 3,87 -3,17 ± 3,56 <0,001* -9,45 ± 2,32
ICP
Median 5,97 -3,47 <0,001** -9,05
Mean ± σ 2,78 ± 1,09 2,83 ± 1,02 0,635 0,05 ± 1,07
Dispersion
Median 2,63 2,61 0,639 0,05
Pulse Mean ± σ 4,97 ± 1,94 5,33 ± 1,92 0,004* 0,36 ± 1,22
pressure Median 4,46 4,91 0,001** 0,35
Mean ± σ 21,51 ± 9,44 23,43 ± 8,43 0,003* 1,91 ± 6,35
dPdt
Median 19,80 21,61 <0,001** 2,46
Mean ± σ 0,248 ± 0,309 0,235 ± 0,287 0,637 -0,013 ± 0,279
RAP index
Median 0,237 0,271 0,407 -0,015
Mean ± σ 0,243 ± 0,392 0,173 ± 0,280 0,046* -0,070 ± 0,345
RPPC
Median 0,204 0,182 0,048** -0,052
Mean ± σ -7,03 ± 15,21 -16,91 ± 10,67 <0,001* -9,88 ± 14,78
P0
Median -5,46 -16,68 <0,001** -11,24
RESULTS

CONTROL iNPH

ICP

ICP dispersion

PP

dPdt

RAP index

RPPC

P0
RESULTS

sHydrocephalus Controls
P
(n=28) (n=31)
Male/Female ratio 1,154 0,823 0,701
Age 60,21 ± 15,94 65,90 ± 18,17 0,208 Secondary hydrocephalus patients
Height
Weight
166,70 ± 9,12
73,54 ± 18,31
160,86 ± 9,19
70,31 ± 11,21
0,048
0,451 • 15 males and 13 females
BMI 27,64 ± 3,62 26,53 ± 3,54 0,329
Supine 7,25 ± 3,82 3,66 ± 3,17 <0,001
ICP Standing -2,36 ± 4,21 -5,62 ± 3,63 0,002
∆ -9,61 ± 3,01 -9,28 ± 2,90 0,669

ICP
Dispersion
Supine
Standing
2,62 ± 1,14
2,57 ± 0,88
1,79 ± 0,94
2,20 ± 0,98
0,003
0,135 Differences with the control group:
∆
Supine
-0,05 ± 1,19
4,22 ± 1,60
0,41 ± 0,80
2,88 ± 0,93
0,329
<0,001
• Height
Pulse
pressure
Standing
∆
4,36 ± 1,68
0,14 ± 1,00
3,58 ± 1,24
0,70 ± 0,75
0,045
0,018
• ΔPP
Supine 20,01 ± 8,41 15,15 ± 6,64 0,016
dPdt Standing 21,35 ± 8,79 17,79 ± 7,17 0,093
∆ 1,33 ± 5,67 2,64 ± 4,96 0,350
Supine 0,363 ± 0,323 0,097 ± 0,297 0,001
RAP index Standing 0,316 ± 0,285 0,161 ± 0,244 0,029
∆ -0,047 ± 0,289 0,064 ± 0,279 0,137
Supine -6,64 ± 6,80 -1,75 ± 13,60 0,092
P0 Standing -18,29 ± 9,90 -15,83 ± 10,15 0,355
∆ -11,64 ± 11,30 -14,08 ± 3,48 0,559
RESULTS

Supine Standing P ∆
Mean ± σ 7,25 ± 3,82 -2,36 ± 4,21 <0,001 -9,61 ± 3,01
ICP
Median 7,30 -3,17 <0,001 -9,64
Mean ± σ 2,62 ± 1,14 2,57 ± 0,88 0,823 -0,05 ± 1,19
Dispersion
Median 2,34 2,39 0,811 -0,09
Pulse Mean ± σ 4,22 ± 1,60 4,36 ± 1,68 0,461 0,14 ± 1,00
pressure Median 3,66 3,96 0,412 0,14
Mean ± σ 20,01 ± 8,41 21,35 ± 8,79 0,224 1,33 ± 5,67
dPdt
Median 18,85 18,70 0,068 1,53
Mean ± σ 0,363 ± 0,323 0,316 ± 0,285 0,394 -0,047 ± 0,289
RAP index
Median 0,349 0,310 0,487 -0,028
Mean ± σ 0,230 ± 0,265 0,200 ± 0,266 0,555 -0,070 ± 0,345
RPPC
Median 0,266 0,190 0,356 -0,052
Mean ± σ -6,64 ± 6,80 -18,29 ± 9,90 <0,001 -11,64 ± 11,30
P0
Median -7,59 -19,40 <0,001 -11,24
RESULTS

CONTROL iNPH secH

ICP

ICP dispersion

PP

dPdt

RAP index

RPPC

P0
RESULTS
Chiari I Controls
P
(n=27) (n=31)
Male/Female ratio 0,421 0,823 0,344
Age 40,48 ± 18,07 65,90 ± 18,17 <0,001 Chiari type I patients
Height 162,30 ± 11,93 160,86 ± 9,19 0,657 • 8 males and 19 females
Weight 70,56 ± 18,04 70,31 ± 11,21 0,952
BMI 26,61 ± 5,94 26,53 ± 3,54 0,959
Supine 8,10 ± 3,97 3,66 ± 3,17 <0,001
ICP Standing 1,08 ± 5,20 -5,62 ± 3,63 <0,001
∆ -7,02 ± 2,32 -9,28 ± 2,90 0,002

ICP
Supine
Standing
2,43 ± 1,02
2,70 ± 1,21
1,79 ± 0,94
2,20 ± 0,98
0,016
0,098
Differences with the control group:
Dispersion
∆ 0,26 ± 1,02 0,41 ± 0,80 0,551 • Age
Pulse
Supine
Standing
4,28 ± 1,99
4,60 ± 1,98
2,88 ± 0,93
3,58 ± 1,24
0,002
0,026 • ΔICP
pressure
∆ 0,31 ± 1,29 0,70 ± 0,75 0,184
Supine 26,60 ± 14,23 15,15 ± 6,64 <0,001
dPdt Standing 26,98 ± 15,29 17,79 ± 7,17 0,007
∆ 0,38 ± 8,26 2,64 ± 4,96 0,222
Supine 0,296 ± 0,344 0,097 ± 0,297 0,018
RAP index Standing 0,334 ± 0,261 0,161 ± 0,244 0,012
∆ 0,038 ± 0,271 0,064 ± 0,279 0,719
Supine -3,91 ± 8,95 -1,75 ± 13,60 0,486
P0 Standing -12,74 ± 13,65 -15,83 ± 10,15 0,337
∆ -8,91 ± 16,75 -14,08 ± 3,48 0,289
 Supine Standing P ∆
Mean ± σ 8,10 ± 3,97 1,08 ± 5,20 <0,001* -7,02 ± 2,32
ICP
Median 8,10 1,88 <0,001** -6,88
Mean ± σ 2,43 ± 1,02 2,70 ± 1,21 0,189* 0,26 ± 1,02
Dispersion
Median 2,36 2,26 0,156** 0,11
Pulse Mean ± σ 4,28 ± 1,99 4,60 ± 1,98 0,216* 0,31 ± 1,29
pressure Median 3,88 3,96 0,116** 0,49
Mean ± σ 26,60 ± 14,23 26,98 ± 15,29 0,813* 0,38 ± 8,26
dPdt
Median 22,93 23,36 0,349** 1,33
Mean ± σ 0,296 ± 0,344 0,334 ± 0,261 0,471* 0,038 ± 0,271
RAP index
Median 0,349 0,386 0,374** 0,044
Mean ± σ 0,213 ± 0,335 0,179 ± 0,459 0,724* -0,034 ± 0,502
RPPC
Median 0,261 0,214 0,848** -0,004
Mean ± σ -3,91 ± 8,95 -12,74 ± 13,65 0,012* -8,91 ± 16,75
P0
Median -0,96 -12,07 0,002** -8,14
RESULTS

CONTRO
L iNPH secH Chiari

ΔICP

Δ ICP dispersion

ΔPP

ΔdPdt

ΔRAP index

ΔRPPC

ΔP0
RESULTS
IIH Controls
P
(n=8) (n=31)
Male/Female ratio 0,142 0,823 0,198
Age 42,63 ± 15,29 65,90 ± 18,17 0,002
Height 165,62 ± 8,13 160,86 ± 9,19 0,210
Weight 77,00 ± 17,15 70,31 ± 11,21 0,203
BMI 28,00 ± 5,79 26,53 ± 3,54 0,412

ICP
Supine
Standing
13,34 ± 2,66
5,04 ± 2,73
3,66 ± 3,17
-5,62 ± 3,63
<0,001
<0,001
Chiari type I patients
∆ -8,31 ± 3,39 -9,28 ± 2,90 0,417 • 1 males and 7 females
Supine 3,78 ± 1,84 1,79 ± 0,94 <0,001
ICP
Standing 3,10 ± 1,04 2,20 ± 0,98 0,028
Dispersion
∆ -0,68 ± 2,22 0,41 ± 0,80 0,029
Supine 5,60 ± 2,67 2,88 ± 0,93 0,024
Pulse
Standing 4,83 ± 2,69 3,58 ± 1,24 0,057
pressure
∆
Supine
-0,75 ± 1,46
23,81 ± 8,39
0,70 ± 0,75
15,15 ± 6,64
0,026
0,004
Differences with the control group:
dPdt Standing
∆
22,99 ± 12,35
-0,82 ± 9,45
17,79 ± 7,17
2,64 ± 4,96
0,250
0,346
• Age
Supine 0,516 ± 0,337 0,097 ± 0,297 0,001 • Δ ICP dispersion
RAP index Standing 0,546 ± 0,243 0,161 ± 0,244 <0,001
∆ 0,029 ± 0,212 0,064 ± 0,279 0,703
Supine 0,402 ± 0,285 0,121 ± 0,387 0,037
RPPC Standing 0,537 ± 0,267 0,140 ± 0,293 0,001
∆ 0,134 ± 0,206 0,018 ± 0,304 0,315
Supine 2,85 ± 4,63 -1,75 ± 13,60 0,357
P0 Standing -5,53 ± 4,70 -15,83 ± 10,15 0,009
∆ -8,38 ± 4,01 -14,08 ± 3,48 0,410
RESULTS

Supine Standing P ∆
Mean ± σ 13,34 ± 2,66 5,04 ± 2,73 <0,001* -8,31 ± 3,39
ICP
Median 12,86 6,08 0,012** -8,96
Mean ± σ 3,78 ± 1,84 3,10 ± 1,04 0,417* -0,68 ± 2,22
Dispersion
Median 3,64 3,03 0,484** -0,10
Pulse Mean ± σ 5,60 ± 2,67 4,83 ± 2,69 0,186* -0,82 ± 9,45
pressure Median 5,47 4,06 0,208** -0,47
Mean ± σ 23,81 ± 8,39 22,99 ± 12,35 0,813* -0,82 ± 9,45
dPdt
Median 21,46 17,96 0,674** -2,18
Mean ± σ 0,516 ± 0,337 0,546 ± 0,243 0,708* 0,029 ± 0,212
RAP index
Median 0,516 0,570 0,674** 0,037
Mean ± σ 0,402 ± 0,285 0,537 ± 0,267 0,108* 0,134 ± 0,206
RPPC
Median 0,449 0,555 0,161** 0,105
Mean ± σ 2,85 ± 4,63 -5,53 ± 4,70 0,001* -8,38 ± 4,01
P0
Median 1,50 -4,11 0,012** -8,52
RESULTS

CONTROL iNPH secH Chiari IIH

ICP

ICP dispersion

PP

dPdt

RAP index

RPPC

P0
DISCUSION

• Patients with NPH

• Subgroup of 20 patients with symptoms of NPH
dispalying a clear difference in ICP with posture
were analyzed to asses the influence of a change
in body position on RAP index.
• 12 patients of this group were shunted
DISCUSION

RAP increases after a change

in body position from sitting
up to horizontal
DISCUSION

Limitations:
No of patients (20)
12 of them were shunted: confusing factor
DISCUSION

• △ICP was significantly higher en patients without

obstruction of the foramen magnum than in those
with Chiari malformation, without differences
between Type I and Type II
INTRODUCTION

Andersen (2015)

We see marked posture-related changes in ICP, but no difference is seen between

patient groups in the measured body postures.
CONCLUSIONS

• Variations of ICP during changes in body posture are similar in subjects with normal ICP
recording and iNPH patients.

• Some previously undescribed peculiarities have been detected in secondary hydrocephalus,

Chiari malformation and pseudotumor cerebri.