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      The significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal


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          Intra-abdominal pressure (IAP) is a physiological parameter that has gained considerable attention during the last few decades. The incidence of complications arising from increased IAP, known as intra-abdominal hypertension (IAH) or abdominal compartment syndrome in critically ill patients, is high and its impact is significant. The effects of IAP in neurological conditions and during surgical procedures are largely unexplored. IAP also appears to be relevant during neurosurgical procedures (spine and brain) in the prone position, and in selected cases, IAH may affect cerebrospinal fluid drainage after a ventriculoperitoneal shunt operation. Furthermore, raised IAP is one of the contributors to intracranial hypertension in patients with morbid obesity. In traumatic brain injury, case reports described how abdominal decompression lowers intracerebral pressure. The anatomical substrate for transmission of the IAP to the brain and venous system of the spine is the extradural neural axis compartment; the first reports of this phenomenon can be found in anatomical studies of the sixteenth century. In this review, we summarize the available knowledge on how IAP impacts the cerebrospinal venous system and the jugular venous system via two pathways, and we discuss the implications for neurosurgical procedures as well as the relevance of IAH in neurological disorders.

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          O V BATSON (1940)
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            What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure?

            To describe what is defined as normal intra-abdominal pressure (IAP) and how body positioning, body mass index (BMI) and positive end-expiratory pressure (PEEP) affect IAP monitoring. A review of different databases was made (Pubmed, MEDLINE (January 1966-June 2007) and EMBASE.com (January 1966-June 2007)) using the search terms of "IAP", "intra-abdominal hypertension" (IAH), "abdominal compartment syndrome" (ACS), "body positioning", "prone positioning", "PEEP" and "acute respiratory distress syndrome" (ARDS). Prior to 1966, we selected older articles by looking at the reference lists displayed in the more recent papers. This review focuses on the concept that the abdomen truly behaves as a hydraulic system. The definitions of a normal IAP in the general patient population and morbidly obese patients are reviewed. Subsequently, factors that affect the accuracy of IAP monitoring, i.e., body position (head of bed elevation, lateral decubitus and prone position) and PEEP, are explored. The abdomen behaves as a hydraulic system with a normal IAP of about 5-7 mmHg, and with higher baseline levels in morbidly obese patients of about 9-14 mmHg. Measuring IAP via the bladder in the supine position is still the accepted standard method, but in patients in the semi-recumbent position (head of the bed elevated to 30 degrees and 45 degrees ), the IAP on average is 4 and 9 mmHg, respectively, higher. Future research should be focused on developing and validating predictive equations to correct for supine IAP towards the semi-recumbent position. Small increases in IAP in stable patients without IAH, turned prone, have no detrimental effects. The role of prone positioning in the unstable patient with or without IAH still needs to be established.
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              Human cerebral venous outflow pathway depends on posture and central venous pressure.

              Internal jugular veins are the major cerebral venous outflow pathway in supine humans. In upright humans the positioning of these veins above heart level causes them to collapse. An alternative cerebral outflow pathway is the vertebral venous plexus. We set out to determine the effect of posture and central venous pressure (CVP) on the distribution of cerebral outflow over the internal jugular veins and the vertebral plexus, using a mathematical model. Input to the model was a data set of beat-to-beat cerebral blood flow velocity and CVP measurements in 10 healthy subjects, during baseline rest and a Valsalva manoeuvre in the supine and standing position. The model, consisting of 2 jugular veins, each a chain of 10 units containing nonlinear resistances and capacitors, and a vertebral plexus containing a resistance, showed blood flow mainly through the internal jugular veins in the supine position, but mainly through the vertebral plexus in the upright position. A Valsalva manoeuvre while standing completely re-opened the jugular veins. Results of ultrasound imaging of the right internal jugular vein cross-sectional area at the level of the laryngeal prominence in six healthy subjects, before and during a Valsalva manoeuvre in both body positions, correlate highly with model simulation of the jugular cross-sectional area (R(2) = 0.97). The results suggest that the cerebral venous flow distribution depends on posture and CVP: in supine humans the internal jugular veins are the primary pathway. The internal jugular veins are collapsed in the standing position and blood is shunted to an alternative venous pathway, but a marked increase in CVP while standing completely re-opens the jugular veins.

                Author and article information

                0031 132210000 , p.depauw@etz.nl
                Acta Neurochir (Wien)
                Acta Neurochir (Wien)
                Acta Neurochirurgica
                Springer Vienna (Vienna )
                25 March 2019
                25 March 2019
                : 161
                : 5
                : 855-864
                [1 ]GRID grid.416373.4, Department of Neurosurgery, , Elisabeth Tweesteden Hospital (ETZ), ; Tilburg, The Netherlands
                [2 ]GRID grid.416373.4, Elisabeth Tweesteden Hospital, ; Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
                [3 ]Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
                [4 ]Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
                [5 ]ISNI 0000000089452978, GRID grid.10419.3d, Department of Neurosurgery, , Leiden University Medical Center (LUMC) and The Hague Medical Center (HMC+), ; Leiden, The Netherlands
                [6 ]ISNI 0000 0004 0626 3362, GRID grid.411326.3, Intensive Care Unit, , University Hospital Brussels (UZB), ; Jette, Belgium
                [7 ]ISNI 0000 0001 2290 8069, GRID grid.8767.e, Faculty of Medicine and Pharmacy, , Vrije Universiteit Brussel (VUB), ; Brussels, Belgium
                [8 ]ISNI 0000 0004 0626 3303, GRID grid.410566.0, Department of Critical Care Medicine, , Ghent University Hospital, ; Ghent, Belgium
                © The Author(s) 2019

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                Review Article - Neurosurgery general
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                © Springer-Verlag GmbH Austria, part of Springer Nature 2019

                vertebral venous system, vvs,intra-abdominal pressure, iap,intra-abdominal hypertension, iah,prone position,idiopathic intracranial hypertension, iih,hydrocephalus,traumatic brain injury, tbi,cerebrospinal venous system, csvs,extradural neural axis compartment, ednac


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