A noninvasive method for the estimation of increased intracranial pressure in patients with severe traumatic brain injury using optic nerve sheath diameter measured on computed tomography head

Background: Measurement of optic nerve sheath diameter (ONSD) using ocular ultrasonography has shown a promise in predicting increased intracranial pressure (ICP). However, this method is dependent on operator technique and equipment availability. We propose an alternative method of measuring ONSD and Marshall score grading by utilizing initial computed tomography (CT) head obtained on admission. We believe that such a technique could help predict patients requiring an invasive ICP monitor on admission. Methods: Patients were retrospectively selected from the neurosurgery database of a level II trauma center. Control patients originated from a database of nontraumatic brain injury (TBI) patients with a negative CT head and no intracranial pathology. Study subjects included patients aged 18–90 years, who sustained a severe TBI requiring placement of an ICP monitor on admission. All patients had a non-contrast CT head before the placement of an ICP monitor. Patients receiving any intervention for decreasing suspected elevated ICPs and those with any documented orbital fractures before ICP monitor placement were excluded from the study. All measurements were performed by at least of two independent assessors. Results: A total of 242 patients were reviewed, of which 204 (100 control and 104 intervention) met inclusion criteria for this study. T he average age in the control group was 49.1 ± 22.9 years old while the average age of the intervention group was 36.9 ± 15.1 years (P < 0.0001). The average Glasgow Coma Scale was 7 in the intervention group. The average ONSD of the control group was 5.73 ± 0.58 mm compared to 6.76 ± 0.83 mm in the intervention group (P < 0.0001). Linear regression analysis demonstrated a statistically significant correlation between ONSD and opening ICP (r = 0.40, P < 0.001) and peak ICP (r = 0.31, P < 0.0001). An ONSD 6.0 mm + Marshall score 3 on initial CT head demonstrated a 92.5% sensitivity, 92.6% specificity, and 96.1% positive predictive value for developing an ICP 20 mmHg during hospitalization. Conclusion: Utilizing ONSD in combination with Marshall score grading on initial CT head is a strong predictor of elevated ICP. These criteria can be used in future studies to develop more objective criteria to guide ICP monitor placement.

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Use of Emergency Department Sonographic Measurement of Optic Nerve Sheath Diameter to Detect Computed Tomography Findings of Increased Intracranial Pressure in Adult Head Injury Patients

Academic Emergency Medicine ◽

10.1197/j.aem.2005.03.392 ◽

2005 ◽

Vol 12 (Supplement 1) ◽

pp. 139-139

Author(s):

M. Neulander

Keyword(s):

Computed Tomography ◽

Emergency Department ◽

Optic Nerve ◽

Head Injury ◽

Intracranial Pressure ◽

Optic Nerve Sheath Diameter ◽

Optic Nerve Sheath ◽

Increased Intracranial Pressure ◽

Nerve Sheath ◽

Adult Head

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Ultrasonographic optic nerve sheath diameter to detect increased intracranial pressure in adults: a meta-analysis

Acta Radiologica ◽

10.1177/0284185118776501 ◽

2018 ◽

Vol 60 (2) ◽

pp. 221-229 ◽

Cited By ~ 10

Author(s):

Sung-Eun Kim ◽

Eun Pyo Hong ◽

Heung Cheol Kim ◽

Si Un Lee ◽

Jin Pyeong Jeon

Keyword(s):

Optic Nerve ◽

Intracranial Pressure ◽

Meta Analysis ◽

Optic Nerve Sheath Diameter ◽

Optic Nerve Sheath ◽

Increased Intracranial Pressure ◽

Summary Receiver Operating Characteristic ◽

Nerve Sheath ◽

Study Characteristics ◽

Meta Regression

Background The optimal optic nerve sheath diameter (ONSD) cut-off for identifying increased intracranial pressure (IICP) remains unclear in adult patients. Purpose To validate the diagnostic accuracy of ultrasonographic (US) ONSD > 5.0 mm as a cut-off for detecting IICP by computed tomographic (CT) through a meta-analysis. Material and Methods A systemic literature review was performed of online databases from January 1990 to September 2017. A bivariate random-effects model was used to estimate pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95% confidence intervals (CIs). A summary receiver operating characteristic (SROC) graph was used to provide summary points for sensitivity and specificity. Meta-regression tests were performed to estimate the influence of the study characteristics on DOR. Publication bias was assessed using Deeks' funnel plot asymmetry test. Results Six studies with 352 patients were included in the meta-analysis. US ONSD > 5.0 mm revealed pooled sensitivity of 99% (95% CI = 96–100) and specificity of 73% (95% CI = 65–80) for IICP detection. DOR was 178. The area under the SROC curve was 0.981, indicating a good level of accuracy. Meta-regression studies showed no significant associations between DOR and study characteristics such as probe mode (relative DOR [RDOR] = 0.60; P = 0.78), study quality (RDOR = 0.52; P = 0.67), IICP prevalence (RDOR = 0.04; P = 0.17), or pathology at admission (RDOR = 1.30; P = 0.87). Conclusion US ONSD > 5.0 mm can be used to rapidly detect IICP in adults in emergency departments and intensive care units. Further meta-analysis based on individual patient-level databases is needed to confirm these results.

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Optic nerve sheath diameter correlates with the presence and severity of acute mountain sickness: evidence for increased intracranial pressure

Yearbook of Sports Medicine ◽

10.1016/s0162-0908(09)79501-7 ◽

2010 ◽

Vol 2010 ◽

pp. 319-320

Author(s):

R.J. Shephard

Keyword(s):

Optic Nerve ◽

Intracranial Pressure ◽

Acute Mountain Sickness ◽

Optic Nerve Sheath Diameter ◽

Optic Nerve Sheath ◽

Increased Intracranial Pressure ◽

Nerve Sheath ◽

Mountain Sickness

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Optic Nerve Sheath Diameter Ultrasound and the Diagnosis of Increased Intracranial Pressure

Critical Care Nursing Clinics of North America ◽

10.1016/j.cnc.2015.10.005 ◽

2016 ◽

Vol 28 (1) ◽

pp. 95-99 ◽

Cited By ~ 7

Author(s):

Christopher Hylkema

Keyword(s):

Optic Nerve ◽

Intracranial Pressure ◽

Optic Nerve Sheath Diameter ◽

Optic Nerve Sheath ◽

Increased Intracranial Pressure ◽

Nerve Sheath

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Accuracy of Noninvasive Intraocular Pressure or Optic Nerve Sheath Diameter Measurements for Predicting Elevated Intracranial Pressure in Cryptococcal Meningitis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofu093 ◽

2014 ◽

Vol 1 (3) ◽

Cited By ~ 20

Author(s):

Henry W. Nabeta ◽

Nathan C. Bahr ◽

Joshua Rhein ◽

Nicholas Fossland ◽

Agnes N. Kiragga ◽

...

Keyword(s):

Intraocular Pressure ◽

Optic Nerve ◽

Intracranial Pressure ◽

Cryptococcal Meningitis ◽

Optic Nerve Sheath Diameter ◽

Diagnostic Value ◽

Optic Nerve Sheath ◽

Increased Intracranial Pressure ◽

Nerve Sheath ◽

Immunodeficiency Virus

Abstract Background. Cryptococcal meningitis is associated with increased intracranial pressure (ICP). Therapeutic lumbar puncture (LP) is recommended when the initial ICP is >250 mm H2O, yet the availability of manometers in Africa is limited and not always used where available. We assessed whether intraocular pressure could be a noninvasive surrogate predictor to determine when additional therapeutic LPs are necessary. Methods. Ninety-eight human immunodeficiency virus-infected Ugandans with suspected meningitis (81% Cryptococcus) had intraocular pressure measured using a handheld tonometer (n = 78) or optic nerve sheath diameter (ONSD) measured by ultrasound (n = 81). We determined the diagnostic performance of these methods for predicting ICP vs a standard manometer. Results. The median ICP was 225 mm H2O (interquartile range [IQR], 135–405 mm H2O). The median intraocular pressure was 28 mm Hg (IQR, 22–37 mm Hg), and median ultrasound ONSD was 5.4 mm (IQR, 4.95–6.1 mm). ICP moderately correlated with intraocular pressure (ρ = 0.45, P < .001) and with ultrasound ONSD (ρ = 0.44, P < .001). There were not discrete threshold cutoff values for either tonometry or ultrasound ONSD that provided a suitable cutoff diagnostic value to predict elevated ICP (>200 mm H2O). However, risk of elevated ICP >200 mm H2O was increased with an average intraocular pressure >28 mm Hg (relative risk [RR] = 3.03; 95% confidence interval [CI], 1.55–5.92; P < .001) or an average of ONSD >5 mm (RR = 2.39; 95% CI, 1.42–4.03; P = .003). As either intraocular pressure or ONSD increased, probability of elevated ICP increased (ie, positive predictive value increased). Conclusions. Noninvasive intraocular pressure measurements by tonometry or ultrasound correlate with cerebrospinal fluid opening pressure, but both are a suboptimal replacement for actual ICP measurement with a manometer.

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The relationship between computed tomography measurement of the optic nerve sheath diameter and elevated intracranial pressure in non-trauma patients

South African Journal of Radiology ◽

10.4102/sajr.v20i1.1060 ◽

2016 ◽

Vol 20 (1) ◽

Cited By ~ 2

Author(s):

Daniël Luyt ◽

Delmé Hurter ◽

Gina Joubert

Keyword(s):

Computed Tomography ◽

Optic Nerve ◽

Intracranial Pressure ◽

Digital Images ◽

Optic Nerve Sheath Diameter ◽

Optic Nerve Sheath ◽

Trauma Patients ◽

Cross Sectional ◽

Nerve Sheath ◽

The Brain

Background: The early detection and treatment of raised intracranial pressure (ICP) is critical in the prevention of mortality and morbidity as a result of secondary ischemic brain injury. Measuring the optic nerve sheath diameter (ONSD) on computed tomography (CT) to predict raised ICP may be useful in cases where routine CT investigations of the brain are indicated and invasive ICP monitoring is not available, or a lumbar puncture (LP) is contraindicated.Objective: The purpose of this study was to determine if the ONSD can be measured on digital images obtained by routine CT investigations of the brain, to identify patients with non-traumatic causes of elevated ICP, and to provide the observer with a non-invasive, objective measurement to predict elevated ICP.Method: We conducted a cross-sectional, retrospective analysis of anonymised patient data, comparing the ONSD on CT imaging with the opening pressure manometry during LP on patients who presented with focal neurology or with a Glasgow coma scale score of less than 15. The study sample consisted of 67 patients, ≥18 years of age, treated at the emergency department of the Kimberly Hospital Complex from 01 March 2013 to 31 December 2014.Results: An ONSD measurement of ≥4.8 mm identified patients with an elevated ICP with a sensitivity of 92.9% and a specificity of 97.6%, using a 95% confidence interval. Raising the ONSD cut-off value to ≥5.0 mm decreased the sensitivity to 85.7% but increased the specificity to 100%, eliminating all patients with a normal ICP.Conclusion: The ONSD can be measured on digital images obtained by routine CT investigations of the brain to predict elevated ICP in non-trauma patients, ≥18 years of age, with acceptable sensitivity and specificity.

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