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      Ocular sonography in patients with raised intracranial pressure: the papilloedema revisited

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      1 , 2 , , 2 , 2
      Critical Care
      BioMed Central

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          Abstract

          Invasive devices are recommended for the early detection of raised intracranial pressure (ICP) after severe traumatic brain injury. Owing to contraindication or local issues, however, invasive ICP monitoring is not always possible. Moreover, a significant proportion of moderate traumatic brain injury patients (managed without invasive ICP) will develop raised ICP. Reliable noninvasive ICP techniques are therefore needed. Soldatos and colleagues report the usefulness of ocular sonography in the diagnosis of raised ICP. Focusing on cerebrospinal fluid accumulation around the retrobulbar optic nerve, they show interesting results for the optic nerve sheath diameter in the diagnosis of raised ICP. If confirmed by further studies, and despite important limitations related to sonography, this technique could serve as a screening test in patients at risk for raised ICP, when invasive monitoring is not possible or is not clearly recommended.

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          Most cited references15

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          Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients.

          Our objective is to determine whether a bedside ultrasonographic measurement of optic nerve sheath diameter can accurately predict the computed tomographic (CT) findings of elevated intracranial pressure in adult head injury patients in the emergency department (ED). We conducted a prospective, blinded observational study on adult ED patients with suspected intracranial injury with possible elevated intracranial pressure. Exclusion criteria were age younger than 18 years or obvious ocular trauma. Using a 7.5-MHz ultrasonographic probe on the closed eyelids, a single optic nerve sheath diameter was measured 3 mm behind the globe in each eye. A mean binocular optic nerve sheath diameter greater than 5.00 mm was considered abnormal. Cranial CT findings of shift, edema, or effacement suggestive of elevated intracranial pressure were used to evaluate optic nerve sheath diameter accuracy. Fifty-nine patients were enrolled in the study. Average age was 38 years, and median Glasgow Coma Scale score was 15 (interquartile 6 to 15). Eight patients with an optic nerve sheath diameter of 5.00 mm or more had CT findings that correlated with elevated intracranial pressure. The sensitivity for the ultrasonography in detecting elevated intracranial pressure was 100% (95% confidence interval [CI] 68% to 100%) and specificity was 63% (95% CI 50% to 76%). The sensitivity of ultrasonography for detection of any traumatic intracranial injury found by CT was 84% (95% CI 60% to 97%) and specificity was 73% (95% CI 59% to 86%). Bedside ED optic nerve sheath diameter ultrasonography has potential as a sensitive screening test for elevated intracranial pressure in adult head injury.
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            Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury.

            To assess at admission to the ICU the relationship between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) and to investigate whether increased ONSD at patient admission is associated with raised ICP in the first 48[Symbol: see text]h after trauma. Prospective, blind, observational study in a surgical critical care unit, level 1 trauma center. 31 adult patients with severe traumatic brain injury (TBI; Glasgow coma scale
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              Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath.

              Patients with altered level of consciousness may be suffering from elevated intracranial pressure (EICP) from a variety of causes. A rapid, portable, and noninvasive means of detecting EICP is desirable when conventional imaging methods are unavailable. The hypothesis of this study was that ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) could accurately predict the presence of EICP. The authors performed a prospective, blinded observational study on emergency department (ED) patients with a suspicion of EICP due to possible focal intracranial pathology. The study was conducted at a large community ED with an emergency medicine residency program and took place over a six-month period. Patients suspected of having EICP by an ED attending were enrolled when study physicians were available. Unstable patients were excluded. ONSD was measured 3 mm behind the globe using a 10-MHz linear probe on the closed eyelids of supine patients, bilaterally. Based on prior literature, an ONSD above 5 mm on ultrasound was considered abnormal. Computed tomography (CT) findings defined as indicative of EICP were the presence of mass effect with a midline shift 3 mm or more, a collapsed third ventricle, hydrocephalus, the effacement of sulci with evidence of significant edema, and abnormal mesencephalic cisterns. For each patient, the average of the two ONSD measurements was calculated and his or her head CT scans were evaluated for signs of EICP. Student's t-test was used to compare ONSDs in the normal and EICP groups. Sensitivity, specificity, and positive and negative predictive values were calculated. Thirty-five patients were enrolled; 14 had CT results consistent with EICP. All cases of CT-determined EICP were correctly predicted by ONSD over 5 mm on US. One patient with ONSD of 5.7 mm in one eye and 3.7 mm in the other on US had a mass abutting the ipsilateral optic nerve; no shift was seen on CT. He was placed in the EICP category on his data collection sheet. The mean ONSD for the 14 patients with CT evidence of EICP was 6.27 mm (95% CI = 5.6 to 6.89); the mean ONSD for the others was 4.42 mm (95% CI = 4.15 to 4.72). The difference of 1.85 mm (95% CI = 1.23 to 2.39 mm) yielded a p = 0.001. The sensitivity and specificity for ONSD, when compared with CT results, were 100% and 95%, respectively. The positive and negative predictive values were 93% and 100%, respectively. Despite small numbers and selection bias, this study suggests that bedside ED US may be useful in the diagnosis of EICP.
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                Author and article information

                Journal
                Crit Care
                Critical Care
                BioMed Central
                1364-8535
                1466-609X
                2008
                16 May 2008
                : 12
                : 3
                : 150
                Affiliations
                [1 ]University Department of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge CB2 2QQ, UK
                [2 ]AP-HP, Univ Paris-Sud, Hôpital Bicêtre, Département d'Anesthésie-Réanimation, F-94275 Le Kremlin-Bicêtre, France
                Article
                cc6893
                10.1186/cc6893
                2481446
                18495051
                4c6df7e4-a907-471f-9908-87a618296772
                Copyright © 2008 BioMed Central Ltd
                History
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                Emergency medicine & Trauma
                Emergency medicine & Trauma

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