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|NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - COMMENTARY
|Year : 2016 | Volume
| Issue : 6 | Page : 1276-1280
Valsalva maneuver: Its implications in clinical neurosurgery
Rudrashish Haldar, Ankur Khandelwal, Devendra Gupta, Shashi Srivastava, Amit Rastogi, Prabhat K Singh
Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||11-Nov-2016|
Dr. Rudrashish Haldar
Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Valsalva maneuver is associated with diverse physiological changes. These changes are used in various diagnostic and therapeutic clinical settings. Valsalva maneuver is also employed during various phases of neurosurgical procedures to achieve specific targets and confirm intraoperative findings. In this article, we attempt to describe the various clinical applications of the Valsalva maneuver within the realms of clinical neurosurgery. The associated complications of this act have also been discussed.
Keywords: Baroreflex; bradycardia; hemostasis; neurosurgery; Valsalva maneuver
|How to cite this article:|
Haldar R, Khandelwal A, Gupta D, Srivastava S, Rastogi A, Singh PK. Valsalva maneuver: Its implications in clinical neurosurgery. Neurol India 2016;64:1276-80
| » Introduction|| |
The initial description of Valsalva maneuver (VM) was given by the Italian physician Anton Maria Valsalva in 1774, when he described it as the act of forced expiration against a closed glottis after a full inspiration. This was done with the purpose of expelling foreign bodies or exudates from the middle ear. Later in 1851, the German physiologist, Edward Weber described in detail, the complicated and significant cardiovascular changes associated with this maneuver., The physiological changes set into motion by this maneuver have found varied clinical applications, which can be diagnostic as well as therapeutic. The diagnostic applications include the evaluation of both the sympathetic and parasympathetic divisions of the autonomic nervous system, thereby helping in the assessment of generalized autonomic failure, autonomic neuropathies, distal small-fiber neuropathy, and adrenergic function. This aids in the quantification of cardiovascular and anesthetic risks in diabetic patients. Additional diagnostic applications include the evaluation of cardiac murmurs and left ventricular function, diagnosis of congestive cardiac failure, enhancement of lower limb color Doppler imaging, and ultrasonic evaluation of biliary obstruction. The therapeutic applications include the termination of supraventricular tachycardias. From the neurosurgical perspective, this maneuver causes sudden expulsion of blood from the thoracic vessels into the carotid vessels causing a rise in the intracranial pressure (ICP), altering the brain perfusion. The altered pressures are further transmitted to the spinal cord. VM has often been been employed during neurosurgical procedures to achieve specific outcomes and confirm the intraoperative finding. This review summarizes the important clinical applications of VM during the different perioperative phases of neurosurgery. The associated complications that have been reported in literature are also discussed.
| » Physiological Changes Associated With Valsalva Maneuver|| |
VM is divided into 4 distinct phases each associated with varied physiological responses.
Phase I: This phase is described from the onset of straining to the early rise of intrathoracic pressure. It shows a rise in the blood pressure; however, the heart rate remains unchanged.
Phase II: This phase is characterized by a decrease in the venous return and the resultant decrease in stroke volume and blood pressure (decreased cardiac output). The baroreceptor reflex is activated causing vasoconstriction and tachycardia (due to autonomic stimulation) in an attempt to bring the blood pressure to normal.
Phase III: This phase consists of blood pooling in the pulmonary vessels consequent to a further drop in the intrathoracic pressure leading to a further fall in blood pressure.
Phase IV: This phase is described by the overshooting of blood pressure above the normal levels and a return of heart rate to its normal level due to the baroreceptor-mediated bradycardia (a compensatory mechanism).
The autonomic system is responsible for controlling the exaggerated responses and involves the baroreceptors, cardiopulmonary, and chemoreceptor reflexes. Hence, VM serves as a test to detect the intactness of the autonomic nervous system.
Changes in intracranial physiology following the Valsalva maneuver
Transcranial Doppler (TCD) studies have demonstrated a direct variation of the intracerebral blood flow velocity (ICBFV). During Phase II, ICBFV dropped by 35%, and during phase IV, ICBFV increased by 56.5%. These changes occur due to the mechanical effects of increased intrathoracic pressure (drop of critical closing pressure at the start of Phase IV), along with stimulation of autonomic neural activity. A significant decrease in the cerebral perfusion pressure has been demonstrated during the strain phase,, and, even though a modest drop is seen in the vascular resistance, it is not of sufficient magnitude or rapidity to ensure a constant cerebral perfusion. This may explain the occasional syncope that may be associated with cough and defecation, which are VM-like maneuvers.
Replication of Valsalva maneuver under anesthesia
In its ideal form, VM is performed in awake patients by generating a pressure of 40 mmHg, which is sustained for 10 seconds against a closed glottis (with nose and mouth closed). Though the classical VM is demonstrated by awake patients, it can also be performed on anesthetized and intubated patients. A passive VM can be performed under anesthesia by squeezing the reservoir bag of the Bain's breathing circuit to maintain a sustained airway pressure of 40 mmHg for 10 seconds at a time.
The clinical applications of VM are divided into the pre and intraoperative periods of neurosurgery.
- Neuroradiological applications: VM has been utilized as an adjunct in various neuroradiological diagnostic studies. Patients with significant carotid artery disease demonstrate altered flow dynamics in the ipsilateral middle cerebral artery (MCA) territory during forced VM. There is uncoupling between the parallel course of ICBFV as well as the systolic blood pressure, with a blunted response of ICBFV in the Phases II and IV. VM has also been used to study the asymmetric blood flow to the brain as a consequence of an existing arteriovenous malformation (AVMs)
- Prediction of postoperative outcome: In addition to testing of the adrenergic autonomic system, VM can be used as a test of the cardiovagal responses. It is assumed that VM aids in identifying patients who are at risk of developing the carotid hypersensitivity syndrome (CHS) following a carotid artery stenting (CAS) procedure. Although Svigelj et al., demonstrated a statistically significant variation in the cardiovagal functions between the baseline (pre-surgical) and post-procedural day, they could not reliably identify the patients who are at risk of developing post-procedural CHS 
- Detecting of radicular or neuropathic pain: The clinical diagnosis of radicular or neuropathic pain of the cervical spine can be facilitated by the use of VM. Upon performing the VM, the intraspinal pressure slightly increases. Thus, neuropathies or radicular pain may become manifest or exacerbated, and this may indicate an impingement of the nerve by an intervertebral disc, osteophytes, or bony compression. Headache and nuchal pain upon performing the VM is also one of the hallmarks of Chiari malformation More Details
- Decreasing the pain during lumbar puncture: Analysis of cerebrospinal fluid is an essential component in the management of various neurological disorders. The cerebrospinal fluid is obtained through a lumbar puncture. VM has been seen to reduce the skin puncture pain associated with needle insertion due to its action on controlling the nociceptive pain. VM has been described as one of the nonpharmacological methods used to reduce the pain of spinal puncture. The mechanism involves the increase in the intrathoracic pressure, which in turn results in baroreceptor activation. Activation of either the cardiopulmonary baroreceptor reflex arc or the sinoaortic baroreceptor reflex arc is believed to induce antinociception.
- Obtaining intravenous (IV) access: Insertion of an IV cannula is a very distressing event for many patients. The efficacy of the VM on the needle insertion pain has been reported in many studies. Agrawal et al., used VM before venous cannulation and observed a significant reduction not only in the severity of pain but also in the number of patients in whom one needed to make the vein prominent before cannulation, and the time taken for performing the venipuncture in adult patients. Venipuncture has been reported to be the most common painful event for a hospitalized child. Gupta et al., studied the efficacy of balloon inflation on venipuncture pain in children aged 6–12 year and demonstrated a significant reduction in the incidence and severity of pain in the children who were given a balloon to inflate compared with those children whose attention was distracted, or in those in the control group in whom no maneuver was adopted to reduce the venipuncture pain. The observed reduction in pain could be secondary to distraction, along with the physiological effect of the VM on pain
- Central venous cannulation: The VM can increase the incidence of successful puncture of the internal jugular vein while performing central venous cannulation. There is a substantial increase in the vascular lumen, especially in those patients in whom the vessel is found to be collapsed (e.g. in hypovolemic patients). The VM significantly increases the cross-sectional area of central veins (>20%), reduces their collapsibility and opens their valves, thereby increasing the success rates of central venous cannulation. Seven percent of jugular lines are reported to be misplaced in the axillary vein, and 5% of subclavian lines are incorrectly positioned. Misplacement of lines and difficulty in cannulating the superior vena cava can occur despite the use of an ultrasound device. Under such circumstances, instead of repositioning the cannula, application of continuous positive airway pressure of approximately 20 cm of H2O maintains the patency of the internal jugular vein and reduces the kinking and locking of the guide wires. Asking the patient to take a deep breath may also straighten the great vessels and help in wire positioning. Moreover, VM decreases the chances of air embolism during the placement of the venous cannula as well as during the removal of the central venous catheters 
- Detecting the integrity of dural repair: During Phase I of VM, the intrathoracic blood is expelled causing an increase in ICP, which is also transmitted to the spinal cord. The transmitted pressure can lead to seepage of cerebrospinal fluid from the dura and arachnoid. Conventionally, VM has been performed during dural closure with the assumption that if no cerebrospinal fluid leakage is detectable from the dura during the VM, then the dural closure is watertight and there would be no subsequent cerebrospinal fluid leakage from the wound., Leakage of cerebrospinal fluid from the dura following application of the VM can also be used to diagnose inadvertent dural tears following surgeries such as microdiscectomies. Conversely, in the cases having cerebrospinal fluid rhinnorhea, VM can be used to locate the site of cerebrospinal fluid leakage so that appropriate repair measures (fat graft, etc.) could be instituted at the focal point of cerebrospinal fluid leakage
- Pituitary surgeries: The VM assumes a position of immense importance during the transsphenoidal excision of pituitary tumors. Application of VM causes descent of the pituitary gland, facilitating tumor resection. Thus, during the transphenoidal approach, VM is often utilized for better visualization and delineation of the suprasellar tumor. Moreover, after excision of the tumor, the VM application can be used to detect cerebrospinal fluid leak from any suprasellar arachnoidal breach as well as to detect the adequacy of hemostasis
- Checking for pleural injuries after taking a rib graft: A graft from the rib is often harvested for onlay placement at the site of vertebral fusion in patients having an atlanto-axial dislocation. Harvesting of rib grafts may lead to inadvertent injury to the pleura, which may lead to the development of pneumothorax during positive pressure ventilation. VM performed, prior to the closure of the operative wound, after irrigating the cavity with saline helps in detecting air bubbles, which signifies the presence of pleural injury
- Prevention of distal particle embolization in patients with AVM: AVMs that require surgical resection can benefit from a preoperative embolization to facilitate shrinkage of the ACM nidus and thus assist in their subsequent surgical resection. However, the drawback of the endovascular approach includes the risk of distal venous deposition or embolization of the embolic substance used by the radiologists or neurosurgeons. It is considered that the risk of venous deposition or distal embolization could be reduced by achieving an extremely low cerebral blood flow (CBF). Harris reported the technique of combining the VM with deliberately induced intraoperative hypotension as a possible approach to induce an extremely low CBF throughout the nidus of the AVM, to reduce the risk of venous deposition or distal embolization at the site of the glue injection 
- Other miscellaneous applications: Apart from the above mentioned uses, VM has been utilized in certain specific scenarios to facilitate the surgical course. Prabhakar et al., have reported the use of VM to assist in the delivery of a neurocysticercal cyst from the fourth ventricle, which the surgeons were not able to grasp. The increase in ICP resulted in the extrusion of the intracranial contents through the dural defect facilitating its delivery. Another report depicts the use of VM in removing the adherent cranial end of the ventriculoperitoneal shunt during a shunt revision procedure. Here, displacement of intracranial contents causing conformational changes around the adherent tip was postulated to be the reason for dislodgement of the shunt. Recinos et al., used a modified minimally invasive periumbilical approach for the peritoneal placement of the ventriculoperitoneal shunt. Here, VM application facilitated the trocar insertion inside the peritoneal cavity.
Complications associated with the Valsalva maneuver
The significant and varied responses of the VM can be associated with a diverse range of neurological complications. Neurological events (syncope) can occur due to a drop in the mean arterial pressures and cerebral perfusion pressures during the strain phase. On the other hand, a rapid rise in the blood pressure after the release phase can cause a supraphysiological rise in cerebrovascular blood flow, which can be responsible for serious neurological consequences such as fainting, rupture of intracranial aneurysms, and rebleeding following hemostasis. The transient decrease in ICP following the VM is liable to expand the size of chronic subdural hematomas. Previously, a few healthy patients who performed VM along with sit ups (a form of physical exercise) have been reported to develop stroke or epidural hematomas. Pneumocephalus can develop following the institution of VM because there is egress of cerebrospinal fluid following a rise in ICP. Air is then sucked inside the cranium to equalize the ICP (negative pressure model). A case reported by Solmaz et al., mentions the development of bilateral tension pneumothorax in a child following shunt surgery. Alveolar overdistention following application of the VM for trocar insertion, which increased the positive pulmonary pressure, was presumed to be responsible for development of this life threatening condition. In the presence of thin walled meningocoeles (which are in a phase of impending rupture), the application of VM application can result in spontaneous cerebrospinal fluid rhinnorhea.
| » Conclusion|| |
VM is associated with profound and complicated physiological responses. Controlled performance of VM can have varied clinical applications within the sphere of neurosurgery. Concurrently, significant complications can occur in the cases where VM application is forceful or prolonged. Therefore, clinicians should be well conversant with its applied physiology and use it judiciously to avoiding the complications associated with it.
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Conflicts of interest
There are no conflicts of interest.
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