The effects of reverse trendelemburg position during intracranial neurosurgery on brain hydrodynamics and hemodynamics: a systematic review and meta-analysis.

Background and objectives: The reverse Trendelenburg position (rTP) tends to reduce jugular bulb pressure (JBP) and intracranial pressure (ICP), and thus improves the operative conditions by increasing brain relaxation. However, through simultaneous decreases in MAP, the cerebral perfusion pressure (CPP) can theoretically decrease, remain unchanged, or increase. We aim to evaluate the effects of rTP on ICP, MAP, JBP, and CPP in intracranial neurosurgery in order to determine the optimal degree of rTP to provide best operating conditions. We also aim to assess the subjective tactile estimation of the dura by neurosurgeons.

Methods: Systematic review and meta-analysis on PubMed, Scopus, and Cochrane Library of studies comparing the effect of rTP with neutral position on ICP, MAP, JBP, and CPP during intracranial neurosurgical procedures.

Results: Five studies were included. For all outcomes, a meta-analysis was only possible for the 10º rTP. The effect of other degrees was not evaluated by more than one study. The mean ICP of patients in the 10º rTP group was lower than in the neutral position group (MD = -4.11mmHg; 95% CI = -5.20mmH to -3.01mmHg; p < 0.00001). The mean MAP (MD = -5.01mmHg; 95% CI = -8.74mmHg to -1.28mmHg; p < 0.008) and mean JBP (MD = -3.92mmHg; 95% CI = -5.38mmHg to -2.47mmHg; p < 0.00001) were also lower in the 10ºrTP group. The CPP remained unchanged between groups (MD = -0.52mmHg; 95% CI = -4.30mmHg to 3.27mmHg; p = 0.79). Estimated dural tension was lower in the 10º rTP group.

Conclusion: When compared to the neutral position, the 10º rTP is effective at lowering ICP and JBP while maintaining CPP unchanged during intracranial neurosurgical procedures, despite a decrease in MAP. It was also associated with lower dural tension. There were no sufficient studies allowing a meta-analysis of other degrees of rTP.