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      Optimal Optic Nerve Sheath Diameter Threshold for the Identification of Elevated Opening Pressure on Lumbar Puncture in a Chinese Population

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          Abstract

          Ultrasonography of the optic nerve sheath diameter (ONSD) is a non-invasive and rapid method that might be helpful in the identification of increased intracranial pressure (ICP). The use of an ONSD greater than 5 mm on ultrasound as an indicator of increased ICP in a Caucasian population has been studied. However, the cut-off point of this predictor in Chinese patients has not been established. Thus, we conducted this study to identify the ONSD criterion for the detection of elevated opening pressure on lumbar puncture (LP) in a Chinese population and to investigate the influencing factors. This study was a blind cross-sectional study. Patients who presented with suspected increased ICP were included. The opening pressure on LP of each participant was confirmed. We analyzed the clinical differences between the groups of patients with abnormal and normal opening pressures on LP. A receiver operating characteristic curve was constructed to determine the ONSD cut-off point for the identification of abnormal opening pressure on LP. In total, 279 patients were recruited, and 101 patients presented with elevated opening pressure on LP. ONSD was a significant independent predictor of elevated opening pressure on LP (p<0.001). However, no statistical significance was observed regarding the factors that might have affected this relationship including gender, age, body mass index, waistline, head circumference, hypertension and pathological subtype. The ONSD cut-off point for the identification of elevated opening pressure on LP was 4.1 mm; this cut-off yielded a sensitivity of 95% and a specificity of 92%. ONSD is a strong and accurate predictor of elevated opening pressure on LP. The cut-off point of this predictor in a Chinese population was remarkably lower than that found in a Caucasian population. Thus, ethnic differences should be noted when using the ONSD as an indicator of increased ICP.

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          Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis.

          Julie Dubourg, Thomas Geeraerts, Etienne Javouhey … (2011)
          To evaluate the diagnostic accuracy of ultrasonography of optic nerve sheath diameter (ONSD) for assessment of intracranial hypertension. Systematic review without language restriction based on electronic databases, with manual review of literature and conference proceedings until July 2010. Studies were eligible if they compared ultrasonography of ONSD with intracranial pressure (ICP) monitoring. Data were extracted independently by three authors. Random-effects meta-analysis and meta-regression were performed. Six studies including 231 patients were reviewed. No significant heterogeneity was detected for sensitivity, specificity, positive and negative likelihood ratios or diagnostic odds ratio. For detection of raised intracranial pressure, pooled sensitivity was 0.90 [95% confidence interval (CI) 0.80-0.95; p for heterogeneity, p (het) = 0.09], pooled specificity was 0.85 (95% CI 0.73-0.93, p (het) = 0.13), and the pooled diagnostic odds ratio was 51 (95% CI 22-121). The area under the summary receiver-operating characteristic (SROC) curve was 0.94 (95% CI 0.91-0.96). Ultrasonography of ONSD shows a good level of diagnostic accuracy for detecting intracranial hypertension. In clinical decision-making, this technique may help physicians decide to transfer patients to specialized centers or to place an invasive device when specific recommendations for this placement do not exist.
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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.

            Philippa Saunders, Vivek S Tayal, Matthew Neulander … (2007)
            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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              Optic nerve ultrasound for the detection of raised intracranial pressure.

              Monique Vanaman, Venkatakrishna Rajajee, Teresa Jacobs … (2011)
              Optic nerve ultrasonography (ONUS) may help identify raised intracranial pressure (ICP). The optimal optic nerve sheath diameter (ONSD) cut-off for the identification of intracranial hypertension has not been established, with some clinical studies suggesting a higher cut-off than may be expected on the basis of prior laboratory investigation. To validate ONUS performed by neurointensivists as a technique for the detection of intracranial hypertension and identify the optimal ONSD criterion for the detection of ICP > 20 mmHg. Prospective blinded observational study. Patients in the ICU with either external ventricular drains or intraparenchymal ICP monitors at risk for intracranial hypertension were enrolled. The ONSD was measured by neurointensivists at the bedside with simultaneous invasive ICP measurement. An ROC curve was constructed to determine the optimal ONSD for the detection of ICP >  20 mmHg. A total of 536 ONSD measurements were performed on 65 patients. Diagnoses included subarachnoid hemorrhage, traumatic brain injury, intracerebral hemorrhage, ischemic stroke and brain tumor. ROC curve analysis revealed area under the curve (AUC) = 0.98 (95% CI 0.96-0.99; P   20 mmHg was ≥0.48 cm sensitivity 96% (95% CI 91-99%); specificity 94% (92-96%). Sensitivity of the higher cutoff of ≥0.52 cm proposed by some authors was only 67% (58-75%), with specificity 98% (97-99%). Bedside ONSD measurement, performed by neurointensivists, is an accurate, non-invasive method to identify ICP > 20 mmHg in a heterogeneous group of patients with acute brain injury. ONSD ≥0.48 cm has the greatest accuracy, however, internal validation of ONSD criteria may be required.
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                Author and article information

                Contributors
                Michele Madigan: Role: Academic Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 9 February 2015
                Publication date Collection: 2015
                Volume: 10
                Issue: 2
                Electronic Location Identifier: e0117939
                Affiliations
                [1 ]The Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
                [2 ]Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
                Save Sight Institute, AUSTRALIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: JF YX LW. Performed the experiments: LW LF YW YC. Analyzed the data: YY LW. Contributed reagents/materials/analysis tools: JF. Wrote the paper: LW.

                Article
                Publisher ID: PONE-D-14-22365
                DOI: 10.1371/journal.pone.0117939
                PMC ID: 4322040
                PubMed ID: 25664663
                SO-VID: ac54c3ce-cd2f-446a-9f4c-c5a2439f15e8
                Copyright statement: Copyright @ 2015
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                History
                Date received : 19 May 2014
                Date accepted : 31 December 2014
                Page count
                Figures: 2, Tables: 1, Pages: 10
                Funding
                The authors received no specific funding for this work.
                Categories
                Subject: Research Article
                Custom metadata
                Data Availability All relevant data are within the paper and its Supporting Information files.

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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