The Impact of Valsalva Manoeuvres and Exercise on Intracranial Pressure and Cerebrovascular Dynamics in Idiopathic Intracranial Hypertension

ABSTRACT

Idiopathic intracranial hypertension (IIH) is a disease characterised by elevated intracranial pressure (ICP). The impact of straining and exercise on ICP regulation is poorly understood yet clinically relevant to IIH patient care. We sought to investigate the impact of Valsalva manoeuvres (VMs) and exercise on ICP and cerebrovascular haemodynamics in IIH. People with IIH were prospectively enrolled and had an intraparenchymal telemetric ICP sensor inserted. Three participants (age [mean ± standard deviation]: 40.3 ± 13.9 years) underwent continuous real-time ICP monitoring coupled with cerebrovascular haemodynamic assessments during VMs and moderate exercise. Participants had IIH with supine ICP measuring 15.3 ± 8.7 mmHg (20.8 ± 11.8 cm cerebrospinal fluid (CSF)) and sitting ICP measuring −4.2 ± 7.9 mmHg (−5.7 ± 10.7 cmCSF). During phase I of a VM ICP increased by 29.4 ± 13.5 mmHg (40.0 ± 18.4 cmCSF) but returned to baseline within 16 seconds from VM onset. The pattern of ICP changes during the VM phases was associated to that of changes in blood pressure, the middle cerebral artery blood velocity and prefrontal cortex haemodynamics. Exercise led to minimal effects on ICP. In conclusion, VM-induced changes in ICP were coupled to cerebrovascular haemodynamics and showed no sustained impact on ICP. Exercise did not lead to prolonged elevation of ICP. Those with IIH experiencing VMs (for example, during exercise and labour) may be reassured at the brief nature of the changes. Future research must look to corroborate the findings in a larger IIH cohort.

KEYWORDS:

• Cerebrovascular haemodynamics
• exercise
• idiopathic intracranial hypertension
• intracranial pressure
• Valsalva maneouvres
• cerebrospinal fluid

Acknowledgments

We thank the patients for their participation and the support of the Wellcome Trust Clinical Research Facility staff, University Hospitals Birmingham NHS Foundation Trust. Infographic created using biorender.com.

Disclosure statement

AY reports receiving speaker fees from Teva, UK, outside the submitted work.

SPM reports other Invex Therapeutics, other Heidelberg engineering during the conduct of the study; other from Chugai-Roche Ltd, other from Janssen, other from Allergan, other from Santen, other from Roche, and other from Neurodiem, outside the submitted work.

AJS reports personal fees from Invex therapeutics in her role as Director with stock holdings, during the conduct of the study; other fees from Allergan, Novartis, Cheisi and Amgen outside the submitted work.

The other authors report no conflicts of interest.

The views expressed are those of the authors and not necessarily those of the UK National Health Service, MoD, NIHR, or the UK department of Health and Social Care.

Role of Funder/Sponsor: The MoD, NIHR and the MRC had no role in the design or conduct of the study; no role in collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript; and no role in the decision to submit the manuscript for publication in the design, execution or write up of this sub-study of the trial.

Authors’contributions

AJS designed the study, secured the funding and served as the senior author of the manuscript and supervised the compilation of data from first author AY and from co-authors.

AJS, JLM, and SJEL contributed to the conception and design of the sub-study.

JLM, SPM, and AJS contributed to patient recruitment.

AY, SRCW, MT, HL, and SJEL performed study visits and contributed to data collection.

AY, SRCW, MT, and SJEL contributed to the data analysis.

AY, SRCW, JLM, MT, SJEL, and AJS contributed to the interpretation of the results.

GT performed surgical implantation of monitors.

AY drafted the manuscript.

All authors contributed to critical revision of the manuscript for important intellectual content and have provided their final approval to submit.

Data availability statement

Anonymised individual participant data can be made available along with the main trial protocol and main trial statistical analysis plan. Proposals should be made to the corresponding author and will be reviewed by the Data Sharing Committee in discussion with the Chief Investigator. A formal Data Sharing Agreement may be required between respective organisations once release of the data is approved and before data can be released.

Ethics approval and consent to participate

This was a sub-study of a prospective clinical study (IIH Pressure Trial: ISRCTN12678718) that was approved by the West Midlands Solihull Research Ethics Committee (17/WM/0179). In accordance with the Declaration of Helsinki, all participants gave written informed consent to participate in the study.

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/01658107.2023.2281433.

Additional information

Funding

AY is funded by an Association of British Neurologists and Guarantors of the Brain fellowship. JLM was funded by the Ministry of Defence (MoD) for the duration of the study. AJS was funded by a National Institute for Health Research (NIHR) clinician scientist fellowship [NIHR-CS-011-028] and the Medical Research Council (MRC), UK [MR/K015184/1] for the duration of the study. AJS is funded by a Sir Jules Thorn Award for Biomedical Science.