Abstract / Summary
Abstract Background Pulmonary complications are common after acute brain injury and may worsen neurologic outcomes. Although prone positioning (PP) is an established treatment strategy for acute respiratory distress syndrome (ARDS) with severe hypoxemia in general intensive care unit populations, it is often avoided in neurocritical care due to concerns that PP may increase intracranial pressure (ICP). However, evidence supporting these concerns remains limited. Methods A systematic search of multiple databases and supplementary sources using keywords related to ICP and PP yielded 778 records. Ten studies with 177 patients met the inclusion criteria for the systematic review and eight ( n = 120 patients) provided extractable data for meta-analysis of the primary outcome [change in ICP from baseline (supine) to PP]. Pooled means and mean differences were calculated using random-effects models. Results The pooled within-subject mean change in ICP from baseline to PP was + 5.06 mm Hg (95% CI 2.05–8.06; I 2 = 76.7%). Accordingly, pooled mean ICP increased from 11.10 mm Hg (95% CI 8.43–13.76) at baseline to 16.13 mm Hg (95% CI 13.83–18.43) during PP, remaining below commonly used treatment thresholds for intracranial hypertension although clinically relevant ICP elevations occurred in a small subset of patients. By contrast, the pooled change in ICP between baseline and after returning to the supine position in five studies ( n = 45) was − 0.41 mm Hg (95% CI − 2.34 to 1.51), indicating that the increase in ICP during PP was transient and reversible. Systemic oxygenation and brain tissue oxygenation improved in PP. Conclusions In patients with acute brain injury, PP improves systemic and brain tissue oxygenation while causing a modest, transient increase in ICP that resolves after resupination. These findings support cautious use of PP in selected neurocritical care patients with respiratory failure when invasive ICP monitoring is available. Given the limited evidence base, larger prospective studies are needed.