The diagnostic performance of ultrasonographic optic nerve sheath diameter and color Doppler indices of the ophthalmic arteries in detecting elevated intracranial pressure

https://doi.org/10.1016/j.clineuro.2015.12.007Get rights and content

Highlights

  • Color Doppler indices of the ophthalmic arteries are inaccurate in detecting increased ICPs.

  • Ultrasonographic ONSD is fully accurate in detecting increased ICPs.

  • There is no difference between the mean binocular and the higher ONSD in detecting increased ICPs.

Abstract

Objectives

To assess the diagnostic accuracy of ultrasonographic optic nerve sheath diameter (ONSD) measurement and color Doppler indices of the ophthalmic arteries in detecting elevated intracranial pressure (ICP).

Patients and methods

A total 60 patients with (cases, n = 30) and without (controls, n = 30) acute clinical and computed tomographic findings of elevated ICP due to intracranial mass/hemorrhage were recruited from a teaching hospital. The mean binocular and maximum ultrasonographic ONSDs, as well as the mean binocular Doppler ultrasound waveform indices of the ophthalmic arteries including pulsatility index (PI), resistive index (RI), end-systolic velocity (ESV), peak systolic velocity (PSV) and end-diastolic velocity (EDV) were compared between the two groups.

Results

Compared to controls, the case group had significantly higher mean binocular ONSD (5.48 ± 0.52 mm vs. 4.09 ± 0.22 mm, p < 0.001), maximum ONSD (5.63 ± 0.55 mm vs. 4.16 ± 0.23 mm, p < 0.001), mean PI (1.53 ± 0.16 vs. 1.45 ± 0.20, p = 0.01), and mean RI (0.76 ± 0.07 vs. 0.73 ± 0.04, p = 0.01). The mean EDV, in contrast, was significantly higher in controls (8.55 ± 3.09 m/s vs. 7.17 ± 2.61 m/s, p = 0.01). The two groups were comparable for the mean PSV (30.73 ± 7.93 m/s in cases vs. 32.27 ± 10.39 m/s in controls, p = 0.36). Among the mentioned variables, the mean binocular ONSD was the most accurate parameter in detecting elevated ICP (sensitivity and specificity of 100%, cut-off point = 4.53 mm). The Doppler indices were only moderately accurate (sensitivity: 56.7  60%, specificity: 63.3  76.7%).

Conclusion

While the ultrasonographic mean binocular ONSD (>4.53 mm) was completely accurate in detecting elevated ICP, color Doppler indices of the ophthalmic arteries were of limited value.

Introduction

Detecting a clinically significant elevation in the intracranial pressure (ICP) is a pivotal step in triage of patients with neurosurgical conditions [1]. At the moment, computed tomography (CT) is considered as the noninvasive method of choice in this regard, but important disadvantages such as the need for patient transportation, being time-consuming and excessive radiation hazards have urged researchers to find other alternatives [2].

In the last decade ultrasonographic techniques including determination of the optic nerve sheath diameter (ONSD) [3], [4], [5] and transcranial Doppler (TCD) examination [6], [7], [8], [9] have been tried to safely detect episodes of increased ICP. Siaudvytyte et al. [8] suggested the ophthalmic arteries as natural ICP sensors and even a TCD-based technique has been devised to use these arteries to estimate intracranial pressure [9]. Technical shortcomings such as inability of ultrasound waves to adequately penetrate the skull [10], [11] and anatomical variations in the transcranial portion of the ophthalmic arteries [12], [13], however, have rendered TCD inaccurate in revealing intracranial hypertension [8], [14], [15]. To obviate these limitations, we hypothesized that Doppler ultrasound waveform indices of the ophthalmic arteries could be used instead of a TCD approach. So, the present study sought to examine this hypothesis in a group of patients with CT findings suggestive of a clinically significant increase in the ICP and a control group including healthy counterparts. At the same time, the accuracy of ultrasonographic ONSD in detecting intracranial hypertension was tested.

Section snippets

Study design and participants

A cohort of 60 subjects including patients with acute clinical and radiological signs of an elevated ICP (cases, n = 30) and subjects with normal ICPs (controls, n = 30) were prospectively recruited from a teaching hospital between May 2014 and March 2015. Obvious ophthalmic injuries or eye pathologies were the exclusion criteria. Before enrollment, informed written consents were obtained from participants. This work was carried out in accordance with the Code of Ethics of the World Medical

Results

The case group comprised 22 males (73.3%) and 8 females (26.8%) with a mean age of 48.40 ± 18.97 years (range, 22–82). In this group the mean Glasgow Coma Scale (GCS) was 8.83 ± 1.53 at the time of admission; and the mean time between the development of symptoms and ONSD measurement was 4.33 ± 1.09 days (range, 3–7). The controls were 15 males (50%) and 15 females (50%) with a mean age of 44.00 ± 16.29 years (range, 18–80). Cases and controls were comparable for their sex (chi-square test, p = 0.06) and

Discussion

The optic nerve sheath is comprised of all three meningeal layers (dura, arachnoid, and pia mater) [16]. In case of a raised ICP the optic nerve diameter increases initially and then papilloedema ensues. So, transorbital ultrasonography could detect an increased ICP earlier than ophthalmoscopy [17]. For the first time in 1968, Hayreh demonstrated a dynamic communication between the intracranial cavity and the subarachnoid space encasing the optic nerve [18]. Twenty-nine years later, Hansen and

Conclusion

While ultrasonographic ONSD was fully accurate in detecting acute elevated ICPs, color Doppler ultrasound examination of the ophthalmic arteries was insufficiently accurate in this regard.

Conflicts of interest

None.

Financial support

None.

Acknowledgment

This study was not supported by any external sources.

References (53)

  • J. Bellner et al.

    Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP)

    Surg. Neurol.

    (2004)
  • T.H. Williamson et al.

    Color Doppler ultrasound imaging of the eye and orbit

    Surv. Ophthalmol.

    (1996)
  • M. Balestreri et al.

    Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury

    Neurocrit. Care

    (2006)
  • The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Initial management

    J. Neurotrauma

    (2000)
  • G.W. Hassen et al.

    Accuracy of optic nerve sheath diameter measurement by emergency physicians using bedside ultrasound

    J. Emerg. Med.

    (2014)
  • J.A. Moreno et al.

    Evaluating the outcome of severe head injury with transcranial Doppler ultrasonography

    Neurosurg. Focus

    (2000)
  • S.G. Voulgaris et al.

    Early cerebral monitoring using the transcranial Doppler pulsatility index in patients with severe brain trauma

    Med. Sci. Monit.

    (2005)
  • L. Siaudvytyte et al.

    Update in intracranial pressure evaluation methods and translaminar pressure gradient role in glaucoma

    Acta Ophthalmol.

    (2015)
  • A. Ragauskas et al.

    Clinical assessment of noninvasive intracranial pressure absolute value measurement method

    Neurology

    (2012)
  • C.J. McMahon et al.

    The reproducibility of transcranial Doppler middle cerebral artery velocity measurements: implications for clinical practice

    Br. J. Neurosurg.

    (2007)
  • G. Tsivgoulis et al.

    Advances in transcranial Doppler ultrasonography

    Curr. Neurol. Neurosci. Rep.

    (2009)
  • Y. Matsumura et al.

    Anatomical variations in the origin of the human ophthalmic artery with special reference to the cavernous sinus and surrounding meninges

    Cells Tissues Organs

    (1999)
  • P. Huynh-Le et al.

    Surgical anatomy of the ophthalmic artery: its origin and proximal course

    Neurosurgery

    (2005)
  • A. Behrens et al.

    Transcranial Doppler pulsatility index: not an accurate method to assess intracranial pressure

    Neurosurgery

    (2010)
  • G. Brandi et al.

    Transcranial color-coded duplex sonography allows to assess cerebral perfusion pressure noninvasively following severe traumatic brain injury

    Acta Neurochir. (Wien)

    (2010)
  • H.E. Killer et al.

    Architecture of arachnoid trabeculae, pillars, and septa in the subarachnoid space of the human optic nerve: anatomy and clinical considerations

    Br. J. Ophthalmol.

    (2003)
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