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Optic Nerve Ultrasound Evaluation in Children: A Review. Diagnostics (Basel) 2023; 13:diagnostics13030535. [PMID: 36766639 PMCID: PMC9914511 DOI: 10.3390/diagnostics13030535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Managing patients with neurocritical illness requires monitoring and treating elevated intracranial pressure (ICP), especially in cases in children. In terms of precise and real-time measurements, invasive ICP measurements are presently the gold standard for the initial diagnosis and follow-up ICP assessments. As a rapid and non-invasive way to detect elevated ICP, point-of-care ultrasonography (POCUS) of optic nerve sheath diameter (ONSD) has been proposed. The utility of bedside POCUS of ONSD to detect elevated ICP with excellent diagnostic test accuracy in adults has already been demonstrated. Nonetheless, data on the relationship between POCUS of ONSD and ICP in children are scarce. Therefore, the purpose of this review is to point out the most recent findings from the pediatric published literature and briefly discuss what was assessed with ONSD ultrasound examination, and also to describe and discuss the diagnostic procedures available for optic nerve ultrasound appraisal. A search of the medical databases PubMed and Scopus was carried out. The terms such as "ocular ultrasonography", "ICP assessment", "children", "point-of-care ultrasound", and "POCUS" were searched. In conclusion, the use of the standardized A-scan technique coupled with the B-scan technique should be suggested to provide data that are as accurate, precise, repeatable, and objective as possible.
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Optic Nerve Sheath Diameter Ultrasound: A Non-Invasive Approach to Evaluate Increased Intracranial Pressure in Critically Ill Pediatric Patients. Diagnostics (Basel) 2022; 12:diagnostics12030767. [PMID: 35328319 PMCID: PMC8946972 DOI: 10.3390/diagnostics12030767] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 01/16/2023] Open
Abstract
Early diagnosis of increased intracranial pressure (ICP) is crucial for prompt diagnosis and treatment of intracranial hypertension in critically ill pediatric patients, preventing secondary brain damage and mortality. Although the placement of an external ventricular drain coupled to an external fluid-filled transducer remains the gold standard for continuous ICP monitoring, other non-invasive approaches are constantly being improved and can provide reliable estimates. The use of point-of-care ultrasound (POCUS) for the assessment of ICP has recently become widespread in pediatric emergency and critical care settings, representing a valuable extension of the physical examination. The aim of this manuscript is to review and discuss the basic principles of ultra-sound measurement of the optic nerve sheath diameter (ONSD) and summarize current evidence on its diagnostic value in pediatric patients with ICP. There is increasing evidence that POCUS measurement of the ONSD correlates with ICP, thus appearing as a useful extension of the physical examination in pediatrics, especially in emergency medicine and critical care settings for the initial non-invasive assessment of patients with suspected raised ICP. Its role could be of value even to assess the response to therapy and in the follow-up of patients with diagnosed intracranial hypertension if invasive ICP monitoring is not available. Further studies on more homogeneous and extensive study populations should be performed to establish ONSD reference ranges in the different pediatric ages and to define cut-off values in predicting elevated ICP compared to invasive ICP measurement.
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Vijay P, Lal BB, Sood V, Khanna R, Patidar Y, Alam S. Dynamic Optic Nerve Sheath Diameter (ONSD) guided management of raised intracranial pressure in pediatric acute liver failure. Hepatol Int 2021; 15:502-509. [PMID: 33625660 DOI: 10.1007/s12072-021-10139-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/16/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS The objectives were to evaluate the role of optic nerve sheath diameter (ONSD) to detect raised intracranial pressure (ICP) in pediatric acute liver failure (PALF), study the variations in ONSD with ICP-lowering measures and to evaluate its prognostic role. METHODS PALF with clinical evidence of raised ICP were enrolled as cases, while those without raised ICP were control group A. ONSD was measured at admission and repeated regularly. It was also measured at time of each new episode of raised ICP and 2 h after the management of such episode. RESULTS 31 PALF with raised ICP were included as cases and 15 without as control group A. ONSD was significantly higher in cases: 5 mm (IQR: 4.7-5.4) as compared to control group A: 3.8 mm (IQR: 3.3-4). ONSD greater than 4.55 mm at baseline diagnosed clinically raised ICP with 87.5% sensitivity and 100% specificity. The mean ONSD was 5.44 ± 0.49 mm during a total of 90 events of acute raised ICP. Clinical responders had a decrease in ONSD by 0.59 ± 0.24 mm by 2 h, whereas non-responders showed a decrease of 0.18 ± 0.23 mm, p < 0.0005. ONSD persisting more than 4.6 mm by 24 h of management predicted poor outcome with sensitivity and specificity of 83.3% and 72.7%. CONCLUSION ONSD is a simple, bedside, inexpensive, reproducible and repeatable modality to assess ongoing change in ICP in PALF. ONSD more than 4.55 mm suggests raised ICP. The goal should be to bring ONSD down to less than 4.6 mm within 24 h by aggressive anti-ICP therapy to achieve favourable outcome.
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Affiliation(s)
- Priti Vijay
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Bikrant Bihari Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Yashwant Patidar
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
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Abstract
Die Optikus-Sonografie bildet Papille, Sehnerv sowie dessen perineuralenLiquorraum ab und eröffnet damit u. a. einen diagnostischen Zugang zumintrakraniellen Liquorsystem und dessen Druck(ICP). Auf diese Weise lässt sich eine relevante ICP-Erhöhung über 20 mmHg nicht-invasiv und bettseitig belegen. Mit Einzelmessungen und Verlaufskontrollen hilft die Methode u. a. vor und nach der Etablierung eines invasiven ICP-Monitorings in der Intensiv- und Notfallmedizin sowie bei der Beurteilung chronischer Dysregulationen des ICP.
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Cardoso FS, Pereira R, Moreno R, Karvellas CJ, Germano N. Optic Nerve Sheath Diameter in Acute Liver Failure: A Prospective Cohort Study. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:170-178. [PMID: 34056039 DOI: 10.1159/000511646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 08/26/2020] [Indexed: 11/19/2022]
Abstract
Introduction Acute liver failure (ALF) is a rare disease that may lead to cerebral edema and death. An increased optic nerve sheath diameter (ONSD) may reflect an early increase in intracranial pressure. We assessed the feasibility and safety of the ONSD measurement and its association with outcomes in patients with ALF. Methods This was an open-label prospective cohort study including adult patients with ALF admitted to a liver-specialized intensive care unit (ICU) in an academic center between October 2018 and February 2020 (among 24): 20 as intention-to-treat and 17 as per-protocol analyses. The ONSD measurement (primary exposure) used an ultrasound transducer (3 determinations on each eye per patient). The primary outcome was hospital mortality. Results Among the 20 patients, 11 (55.0%) were females and the mean age was 45 ± 16 years. On the day of ONSD measurement (median 32.4 h post-ICU admission; IQR 19.8-59.8): 8 patients (40.0%) were in a coma, the mean international normalized ratio (INR) was 3.3 ± 1.4, median bilirubin was 12.3 mg/dL (IQR 4.7-24.5), mean ammonia was 163 ± 101 µmol/L, and mean SOFA score was 11 ± 5. The mean bilateral ONSD was 5.6 ± 0.7 mm, with a very good correlation between right and left eyes (Pearson's r = 0.90). Ten (50.0%) patients were transplanted and 13 (65.0%) patients survived the hospital stay (all with a 2-month extended Glasgow Outcome Scale of 8). The mean ONSD was significantly higher for hospital non-survivors than survivors both in the intention-to-treat (6.2 vs. 5.3 mm; p = 0.004) and per-protocol (6.2 vs. 5.2 mm; p = 0.004) analyses. No adverse effects from ONSD measurements were reported. Conclusions In patients with ALF, a higher ONSD was associated with higher hospital mortality. ONSD measurement is feasible and safe and may have prognostic value.
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Affiliation(s)
| | - Rui Pereira
- Intensive Care Unit, Curry Cabral Hospital, Lisbon, Portugal
| | - Rui Moreno
- Neurointensive Care Unit, São José Hospital, Lisbon, Portugal
| | | | - Nuno Germano
- Intensive Care Unit, Curry Cabral Hospital, Lisbon, Portugal
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Canac N, Jalaleddini K, Thorpe SG, Thibeault CM, Hamilton RB. Review: pathophysiology of intracranial hypertension and noninvasive intracranial pressure monitoring. Fluids Barriers CNS 2020; 17:40. [PMID: 32576216 PMCID: PMC7310456 DOI: 10.1186/s12987-020-00201-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/11/2020] [Indexed: 12/30/2022] Open
Abstract
Measurement of intracranial pressure (ICP) is crucial in the management of many neurological conditions. However, due to the invasiveness, high cost, and required expertise of available ICP monitoring techniques, many patients who could benefit from ICP monitoring do not receive it. As a result, there has been a substantial effort to explore and develop novel noninvasive ICP monitoring techniques to improve the overall clinical care of patients who may be suffering from ICP disorders. This review attempts to summarize the general pathophysiology of ICP, discuss the importance and current state of ICP monitoring, and describe the many methods that have been proposed for noninvasive ICP monitoring. These noninvasive methods can be broken down into four major categories: fluid dynamic, otic, ophthalmic, and electrophysiologic. Each category is discussed in detail along with its associated techniques and their advantages, disadvantages, and reported accuracy. A particular emphasis in this review will be dedicated to methods based on the use of transcranial Doppler ultrasound. At present, it appears that the available noninvasive methods are either not sufficiently accurate, reliable, or robust enough for widespread clinical adoption or require additional independent validation. However, several methods appear promising and through additional study and clinical validation, could eventually make their way into clinical practice.
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Jenjitranant P, Tunlayadechanont P, Prachanukool T, Kaewlai R. Correlation between optic nerve sheath diameter measured on imaging with acute pathologies found on computed tomography of trauma patients. Eur J Radiol 2020; 125:108875. [DOI: 10.1016/j.ejrad.2020.108875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/21/2020] [Accepted: 02/06/2020] [Indexed: 11/29/2022]
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8
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Das MC, Srivastava A, Yadav RK, Yachha SK, Poddar U. Optic nerve sheath diameter in children with acute liver failure: A prospective observational pilot study. Liver Int 2020; 40:428-436. [PMID: 31549476 DOI: 10.1111/liv.14259] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Early detection of raised intracranial pressure (ICP) improves outcome in acute liver failure (ALF). We evaluated the feasibility of bedside, ultrasound-guided measurement of optic nerve sheath diameter (ONSD) in normal and ALF children and correlation of ONSD with grade of hepatic encephalopathy (HE), international normalized ratio (INR) and blood ammonia (BA). METHODS Forty-one ALF and 47 healthy children (5-18 years) were prospectively enrolled and 12 hourly clinical evaluation was done. Laboratory parameters including INR and BA were recorded. ONSD was measured at admission, change in HE grade and at recovery in ALF, and once in controls. RESULTS One hundred and twenty-one ONSD measurements (ALF-74, controls-47) were taken without complications. ONSD was 4.2 (3.9-4.3), 4.4 (4.0-4.6), 5.2 (4.8-5.8) and 3.9 (3.3-4.1) mm in controls, ALF without HE, with HE and at recovery respectively. ONSD was significantly higher in ALF with HE than those without HE. ALF without HE and at recovery had ONSD similar to controls. ONSD was higher in ALF with the clinical signs of raised ICP than those without (5.4 [4.9-5.7] vs 4.6 [4.1-5.3] mm; P = .01). ONSD of 4.6 mm differentiated ALF with HE vs without HE and 5.1 mm between poor vs good non-transplant outcome with ≥80% sensitivity and specificity. ONSD positively correlated with INR (r = .53, P < .001) and BA (r = .42, P = .002). CONCLUSIONS ONSD can be safely and easily measured in ALF children and correlates with HE grade, INR and BA. Normal ONSD in children (>4 years) is <4.5 mm and value of >5.1 mm in ALF requires urgent attention.
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Affiliation(s)
- Mridul C Das
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Rajanikant K Yadav
- Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Surender K Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Reynolds AS, Brush B, Schiano TD, Reilly KJ, Dangayach NS. Neurological Monitoring in Acute Liver Failure. Hepatology 2019; 70:1830-1835. [PMID: 31077591 DOI: 10.1002/hep.30760] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 05/08/2019] [Indexed: 12/28/2022]
Affiliation(s)
- Alexandra S Reynolds
- Department of Neurosurgery, The Mount Sinai Hospital, New York, NY.,Department of Neurology, The Mount Sinai Hospital, New York, NY
| | - Benjamin Brush
- Department of Neurology, The Mount Sinai Hospital, New York, NY
| | | | - Kaitlin J Reilly
- Department of Neurosurgery, The Mount Sinai Hospital, New York, NY.,Department of Neurology, The Mount Sinai Hospital, New York, NY
| | - Neha S Dangayach
- Department of Neurosurgery, The Mount Sinai Hospital, New York, NY.,Department of Neurology, The Mount Sinai Hospital, New York, NY
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Hunt A, Tasker RC, Deep A. Neurocritical care monitoring of encephalopathic children with acute liver failure: A systematic review. Pediatr Transplant 2019; 23:e13556. [PMID: 31407855 DOI: 10.1111/petr.13556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/14/2019] [Accepted: 07/04/2019] [Indexed: 12/15/2022]
Abstract
Research on non-invasive neuromonitoring specific to PALF is limited. This systematic review identifies and synthesis the existing literature on non-invasive approaches to monitoring for neurological sequelae in patients with PALF. A series of literature searches were performed to identify all publications pertaining to five different non-invasive neuromonitoring modalities, in line with PRISMA guidelines. Each modality was selected on the basis of its potential for direct or indirect measurement of cerebral perfusion; studies on electroencephalographic monitoring were therefore not sought. Data were recorded on study design, patient population, comparator groups, and outcomes. A preponderance of observational studies was observed, most with a small sample size. Few incorporated direct comparisons of different modalities; in particular, comparison to invasive intracranial pressure monitoring was largely lacking. The integration of current evidence is considered in the context of the clinically significant distinctions between pediatric and adult ALF, as well as the implications for planning of future investigations to best support the evidence-based clinical care of these patients.
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Affiliation(s)
- Adam Hunt
- University College Hospital, London, UK
| | - Robert C Tasker
- Harvard Medical School, Chair in Neurocritical Care, Boston Children's Hospital, Boston, MA
| | - Akash Deep
- Paediatric Intensive Care, King's College Hospital, London, UK
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11
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Robba C, Goffi A, Geeraerts T, Cardim D, Via G, Czosnyka M, Park S, Sarwal A, Padayachy L, Rasulo F, Citerio G. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med 2019; 45:913-927. [PMID: 31025061 DOI: 10.1007/s00134-019-05610-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Geeraerts
- Department of Anaesthesia and Intensive Care, University Hospital of Toulouse, Toulouse NeuroImaging Center (ToNIC), Inserm-UPS, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University, New York, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Llewellyn Padayachy
- Department of Neurosurgery, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Frank Rasulo
- Department of Anaesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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12
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Ardell S, Daspal S, Holt T, Hansen G. Optic Nerve Sheath Diameter for Preterm Infants: A Pilot Study. Neonatology 2019; 116:1-5. [PMID: 30889584 DOI: 10.1159/000497163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 01/22/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In preterm infants, early diagnosis and management of a raised intracranial pressure (ICP) may be important to improve neurodevelopmental outcomes. While invasive ICP monitoring is not recommended, ultrasonography of the optic nerve sheath diameter (ONSD) could provide a noninvasive alternative to evaluate ICP. The objective of this pilot study was to document ranges of ONSD in preterm infants. METHODS This prospective cohort pilot evaluated preterm infants who were admitted to the neonatal intensive care unit without suspected raised ICP. Three images per eye were obtained from a 20-5 MHz linear array ultrasound transducer placed on the patient's superior eyelid. The OSND was measured 3 mm behind the globe. A second ultrasonographer duplicated half of the scans. Multiple linear regression analysis was conducted for both right and left ONSD with corrected gestational age, weight, and head circumference as predictors. Lin's concordance assessed interrater reliability. RESULTS In 12 preterm infants 114 scans were performed on both eyes. The median age was 33 weeks (corrected gestational age) with a range of 29-36 weeks. Corrected gestational age was the strongest predictor for ONSD, and preliminary measurements at each gestational age were established. Interrater reliability demonstrated substantial agreement (Qc = 0.97). CONCLUSION In preterm infants, ONSD strongly correlates with corrected gestational age. These data should be validated with other imaging modalities before abnormal ranges can be considered.
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Affiliation(s)
- Sarah Ardell
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Sibasis Daspal
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Tanya Holt
- Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gregory Hansen
- Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada,
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13
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Rajajee V, Williamson CA, Fontana RJ, Courey AJ, Patil PG. Noninvasive Intracranial Pressure Assessment in Acute Liver Failure. Neurocrit Care 2018; 29:280-290. [DOI: 10.1007/s12028-018-0540-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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14
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Rajajee V, Fontana RJ, Courey AJ, Patil PG. Protocol based invasive intracranial pressure monitoring in acute liver failure: feasibility, safety and impact on management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:178. [PMID: 28693567 PMCID: PMC5504795 DOI: 10.1186/s13054-017-1762-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/19/2017] [Indexed: 01/20/2023]
Abstract
Background Acute liver failure (ALF) may result in elevated intracranial pressure (ICP). While invasive ICP monitoring (IICPM) may have a role in ALF management, these patients are typically coagulopathic and at risk for intracranial hemorrhage (ICH). Contemporary ICP monitoring techniques and coagulopathy reversal strategies may be associated with a lower risk of hemorrhage. Our objective was to evaluate the safety, feasibility, impact on clinical management and outcomes associated with protocol-directed use of IICPM in ALF. Methods Adult patients admitted between June 2011 and October 2016, with ALF and grade-4 encephalopathy with a reasonable likelihood of survival, were eligible for IICPM. The coagulopathy reversal protocol included administration of recombinant Factor VIIa (rFVIIa) and desmopressin, a goal platelet count >50,000/mm3 and fibrinogen >100 mg/dL. Monitor insertion was performed within an hour of the rFVIIa dose. Only intraparenchymal monitors were used. Computed tomography of the brain was performed prior to and within 24 hours of monitor placement. Outcomes of interest included ICH, sustained intracranial hypertension, therapeutic intensity level (TIL) for ICP management, mortality and functional outcome on the Glasgow Outcome Scale (GOS) at discharge and 6 months. Results A total of 24/37 patients (65%) with ALF underwent IICPM. The most common reason for exclusion was encephalopathy grade <4. Four patients underwent liver transplantation. There was one asymptomatic ICH following IICPM, in a patient who had an excellent outcome. Sustained intracranial hypertension occurred in 13/24 monitored patients (54%), 5/24 (21%) required extreme measures (TIL-4) for ICP control, which were successful in 4 patients: 12/24 patients (50%) died but only 4 deaths (17%) were attributed to intracranial hypertension. Six of the 8 survivors with 6-month follow up had good functional outcome (GOS >3). Conclusions Protocol-directed use of IICPM in ALF is feasible, associated with a low incidence of serious complications and has a significant impact on clinical management.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurosurgery and Neurology, University of Michigan, 3552 Taubman Health Care Center, 1500 East Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109-5338, USA.
| | - Robert J Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Anthony J Courey
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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Robba C, Cardim D, Tajsic T, Pietersen J, Bulman M, Donnelly J, Lavinio A, Gupta A, Menon DK, Hutchinson PJA, Czosnyka M. Ultrasound non-invasive measurement of intracranial pressure in neurointensive care: A prospective observational study. PLoS Med 2017; 14:e1002356. [PMID: 28742869 PMCID: PMC5526499 DOI: 10.1371/journal.pmed.1002356] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 06/14/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The invasive nature of the current methods for monitoring of intracranial pressure (ICP) has prevented their use in many clinical situations. Several attempts have been made to develop methods to monitor ICP non-invasively. The aim of this study is to assess the relationship between ultrasound-based non-invasive ICP (nICP) and invasive ICP measurement in neurocritical care patients. METHODS AND FINDINGS This was a prospective, single-cohort observational study of patients admitted to a tertiary neurocritical care unit. Patients with brain injury requiring invasive ICP monitoring were considered for inclusion. nICP was assessed using optic nerve sheath diameter (ONSD), venous transcranial Doppler (vTCD) of straight sinus systolic flow velocity (FVsv), and methods derived from arterial transcranial Doppler (aTCD) on the middle cerebral artery (MCA): MCA pulsatility index (PIa) and an estimator based on diastolic flow velocity (FVd). A total of 445 ultrasound examinations from 64 patients performed from 1 January to 1 November 2016 were included. The median age of the patients was 53 years (range 37-64). Median Glasgow Coma Scale at admission was 7 (range 3-14), and median Glasgow Outcome Scale was 3 (range 1-5). The mortality rate was 20%. ONSD and FVsv demonstrated the strongest correlation with ICP (R = 0.76 for ONSD versus ICP; R = 0.72 for FVsv versus ICP), whereas PIa and the estimator based on FVd did not correlate with ICP significantly. Combining the 2 strongest nICP predictors (ONSD and FVsv) resulted in an even stronger correlation with ICP (R = 0.80). The ability to detect intracranial hypertension (ICP ≥ 20 mm Hg) was highest for ONSD (area under the curve [AUC] 0.91, 95% CI 0.88-0.95). The combination of ONSD and FVsv methods showed a statistically significant improvement of AUC values compared with the ONSD method alone (0.93, 95% CI 0.90-0.97, p = 0.01). Major limitations are the heterogeneity and small number of patients included in this study, the need for specialised training to perform and interpret the ultrasound tests, and the variability in performance among different ultrasound operators. CONCLUSIONS Of the studied ultrasound nICP methods, ONSD is the best estimator of ICP. The novel combination of ONSD ultrasonography and vTCD of the straight sinus is a promising and easily available technique for identifying critically ill patients with intracranial hypertension.
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Affiliation(s)
- Chiara Robba
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Neuroscience, University of Genoa, Genoa, Italy
| | - Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Tamara Tajsic
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Justine Pietersen
- Department of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Michael Bulman
- Department of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Andrea Lavinio
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Arun Gupta
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K. Menon
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | | | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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Ultrasonographic optic nerve sheath diameter for predicting elevated intracranial pressure during laparoscopic surgery: a systematic review and meta-analysis. Surg Endosc 2017. [DOI: 10.1007/s00464-017-5653-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Szmygel Ł, Kosiak W, Zorena K, Myśliwiec M. Optic Nerve and Cerebral Edema in the Course of Diabetic Ketoacidosis. Curr Neuropharmacol 2017; 14:784-791. [PMID: 26915420 PMCID: PMC5333594 DOI: 10.2174/1570159x14666160225155151] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 11/11/2015] [Accepted: 11/15/2015] [Indexed: 11/22/2022] Open
Abstract
In the recent years we have been observing an increased incidence of type 1 diabetes in children and adolescents. This leads to a more frequent acute complication of type 1 diabetes among children with hyperglycemia. The most common of these is diabetic ketoacidosis (DKA), while cerebral edema is the most dangerous. In children with DKA, cerebral edema most often presents with clinical symptoms but may also appear in the so-called "subclinical" form. That is why the search continues for new methods of assessing and monitoring cerebral edema in the course of DKA treatment. Ultrasonographic optic nerve sheath diameter (US ONSD) assessment is performed in various clinical scenarios when cerebral edema is suspected. It is most often performed in adult patients but increasingly often in children. US ONSD assessment is useful in the treatment of DKA in children with type 1 diabetes. This manuscript provides an overview of research results available in PubMed and other available databases on the course of treatment of DKA in children with type 1 diabetes.
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Affiliation(s)
- Łukasz Szmygel
- Clinic of Pediatrics Diabetology and Endocrinology, Medical University of Gdansk, 80-952 Gdansk, Poland
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Robba C, Bacigaluppi S, Cardim D, Donnelly J, Bertuccio A, Czosnyka M. Non-invasive assessment of intracranial pressure. Acta Neurol Scand 2016; 134:4-21. [PMID: 26515159 DOI: 10.1111/ane.12527] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 11/29/2022]
Abstract
Monitoring of intracranial pressure (ICP) is invaluable in the management of neurosurgical and neurological critically ill patients. Invasive measurement of ventricular or parenchymal pressure is considered the gold standard for accurate measurement of ICP but is not always possible due to certain risks. Therefore, the availability of accurate methods to non-invasively estimate ICP has the potential to improve the management of these vulnerable patients. This review provides a comparative description of different methods for non-invasive ICP measurement. Current methods are based on changes associated with increased ICP, both morphological (assessed with magnetic resonance, computed tomography, ultrasound, and fundoscopy) and physiological (assessed with transcranial and ophthalmic Doppler, tympanometry, near-infrared spectroscopy, electroencephalography, visual-evoked potentials, and otoacoustic emissions assessment). At present, none of the non-invasive techniques alone seem suitable as a substitute for invasive monitoring. However, following the present analysis and considerations upon each technique, we propose a possible flowchart based on the combination of non-invasive techniques including those characterizing morphologic changes (e.g., repetitive US measurements of ONSD) and those characterizing physiological changes (e.g., continuous TCD). Such an integrated approach, which still needs to be validated in clinical practice, could aid in deciding whether to place an invasive monitor, or how to titrate therapy when invasive ICP measurement is contraindicated or unavailable.
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Affiliation(s)
- C. Robba
- Neurosciences Critical Care Unit; Addenbrooke's Hospital; Cambridge United Kingdom
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - S. Bacigaluppi
- Department of Neurosurgery; Galliera Hospital; Genova Italy
| | - D. Cardim
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - J. Donnelly
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - A. Bertuccio
- Department of Neurosurgery; S. George's Hospital; University of London; United Kingdom
| | - M. Czosnyka
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
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Ilie LA, Thomovsky EJ, Johnson PA, Bentley RT, Heng HG, Lee HC, Moore GE. Relationship between intracranial pressure as measured by an epidural intracranial pressure monitoring system and optic nerve sheath diameter in healthy dogs. Am J Vet Res 2016. [PMID: 26207971 DOI: 10.2460/ajvr.76.8.724] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the association between ultrasonographically measured optic nerve sheath diameter (ONSD) and acute increases in intracranial pressure (ICP) as measured by an epidural intracranial pressure monitoring system (EICPMS) in healthy dogs. ANIMALS 6 young healthy dogs. PROCEDURES An EICPMS connected to a pressure monitor was used to generate a continuous pressure waveform in each anesthetized dog. A 22-gauge IV catheter was inserted into the brain parenchyma through the contralateral parietal bone, and 0.5 to 2.0 mL of anticoagulated autologous blood was injected at predetermined intervals. At baseline (immediately after EICPMS placement) and following each injection, the ICP as indicated by EICPMS was recorded, and 3 ultrasonographic images of the optic nerve sheath of each eye were obtained. The ONSD was measured at maximum diameter and at 5 mm caudal to the optic disk. RESULTS In linear models, the maximum ONSD was positively associated with increasing ICP. Specifically, the rate of maximum ONSD increase was greater for pressures ≤ 20 mm Hg above baseline (0.0534 mm/1 mm Hg ICP increase) than for pressures > 40 mm Hg above baseline (0.0087 mm/1 mm Hg ICP increase). The relationship of ICP to maximum ONSD was slightly nonlinear and best explained by comparison of fractional polynomial regression models. CONCLUSIONS AND CLINICAL RELEVANCE ICP was positively and nonlinearly associated with increasing maximum ONSD, especially when ICP was ≤ 20 mm Hg above baseline, supporting the conclusion that ultrasonographic measurement of maximum ONSD may provide a noninvasive monitoring tool for evaluation of ICP in dogs. Further research is needed to assess the utility of these measurements in clinical patients.
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Ko SB. Optic Nerve Sheath Diameter on Brain Magnetic Resonance Imaging: A Single Center Study. JOURNAL OF NEUROCRITICAL CARE 2015. [DOI: 10.18700/jnc.2015.8.1.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Sangani SV, Parikh S. Can sonographic measurement of optic nerve sheath diameter be used to detect raised intracranial pressure in patients with tuberculous meningitis? A prospective observational study. Indian J Radiol Imaging 2015; 25:173-6. [PMID: 25969641 PMCID: PMC4419427 DOI: 10.4103/0971-3026.155869] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
CNS Tuberculosis can manifest as meningitis, arachnoiditis and a tuberculoma. The rupture of a tubercle into the subarachnoid space leads to Tuberculosis Meningitis (TBME); the resulting hypersensitivity reaction can lead to an elevation of the intracranial pressure and hydrocephalus. While bedside optic nerve sheath diameter (ONSD) ultrasonography (USG) can be a sensitive screening test for elevated intracranial pressure in adult head injury, little is known regarding ONSD measurements in Tuberculosis Meningitis.
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Affiliation(s)
- Shruti V Sangani
- Department of Emergency Medicine, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| | - Samira Parikh
- Department of Emergency Medicine, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, India
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Min JY, Lee JR, Oh JT, Kim MS, Jun EK, An J. Ultrasonographic assessment of optic nerve sheath diameter during pediatric laparoscopy. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:1241-1246. [PMID: 25726135 DOI: 10.1016/j.ultrasmedbio.2015.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 01/07/2015] [Accepted: 01/16/2015] [Indexed: 06/04/2023]
Abstract
This study investigated the extent of the raised intracranial pressure resulting from carbon dioxide (CO2) pneumoperitoneum by ultrasonographically measuring optic nerve sheath diameter (ONSD) in children undergoing laparoscopic surgery. Twenty-five children aged less than 9 y (53.1 ± 23.3 mo, mean ± standard deviation) and scheduled for an elective laparoscopic surgery participated. ONSD was assessed using ocular ultrasonography 10 min after induction of anesthesia (T0), 10 min after induction of CO2 pneumoperitoneum at 10 mm Hg intra-abdominal pressure (T1) and in an anesthetized state without CO2 pneumoperitoneum at the conclusion of the surgery (T2). During CO2 pneumoperitoneum, ONSD increased significantly compared with ONSD after anesthesia induction (T0: 4.3 ± 0.3 mm, T1: 4.6 ± 0.3 mm, p < 0.05). In all enrolled patients, any neurologic complications were not observed during the intra-operative or post-operative period. In children undergoing laparoscopic surgery, an increase in ONSD was ascertained during CO2 pneumoperitoneum, and thus the corresponding increase in intracranial pressure could be predicted.
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Affiliation(s)
- Ji Young Min
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Rim Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Tak Oh
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min-Soo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun-Kyung Jun
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jiwon An
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Tawfik EA, Walker FO, Cartwright MS. Neuromuscular ultrasound of cranial nerves. J Clin Neurol 2015; 11:109-21. [PMID: 25851889 PMCID: PMC4387476 DOI: 10.3988/jcn.2015.11.2.109] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 10/27/2014] [Accepted: 10/28/2014] [Indexed: 02/06/2023] Open
Abstract
Ultrasound of cranial nerves is a novel subdomain of neuromuscular ultrasound (NMUS) which may provide additional value in the assessment of cranial nerves in different neuromuscular disorders. Whilst NMUS of peripheral nerves has been studied, NMUS of cranial nerves is considered in its initial stage of research, thus, there is a need to summarize the research results achieved to date. Detailed scanning protocols, which assist in mastery of the techniques, are briefly mentioned in the few reference textbooks available in the field. This review article focuses on ultrasound scanning techniques of the 4 accessible cranial nerves: optic, facial, vagus and spinal accessory nerves. The relevant literatures and potential future applications are discussed.
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Affiliation(s)
- Eman A Tawfik
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Francis O Walker
- Department of Neurology, Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Michael S Cartwright
- Department of Neurology, Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Chin JH, Seo H, Lee EH, Lee J, Hong JH, Hwang JH, Kim YK. Sonographic optic nerve sheath diameter as a surrogate measure for intracranial pressure in anesthetized patients in the Trendelenburg position. BMC Anesthesiol 2015; 15:43. [PMID: 25861241 PMCID: PMC4389861 DOI: 10.1186/s12871-015-0025-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/19/2015] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND It remains to be elucidated whether the Trendelenburg position increases intracranial pressure (ICP). ICP can be evaluated by measuring the sonographic optic nerve sheath diameter (ONSD). We investigated the effect of the isolated Trendelenburg position on ONSD in patients undergoing robot-assisted laparoscopic radical prostatectomy. Additionally, we evaluated the effect of the Trendelenburg position combined with pneumoperitoneum on ONSD. METHODS Twenty-one patients scheduled for robot-assisted laparoscopic radical prostatectomy were enrolled. Sonographic ONSDs and hemodynamic parameters were measured at specific time points: in the supine position after induction of anesthesia, 3 min after the steep Trendelenburg position (35° incline), 3 min after the steep Trendelenburg position combined with pneumoperitoneum, and in the supine position after desufflation of the pneumoperitoneum. RESULTS The ONSD 3 min after the steep Trendelenburg position was significantly higher than that of the supine position after induction of anesthesia (5.1 ± 0.3 mm vs. 4.5 ± 0.4 mm). In addition, the ONSD 3 min after the steep Trendelenburg position combined with pneumoperitoneum was higher than that of the supine position after induction of anesthesia (4.9 ± 0.4 mm vs. 4.5 ± 0.4 mm). The ONSD in the supine position after desufflation of the pneumoperitoneum was similar to that in the supine position after induction of anesthesia. CONCLUSIONS Use of the isolated steep Trendelenburg position, for even a short duration, increased the sonographic ONSD, providing a better understanding of the effect of only a transient steep Trendelenburg position on ONSD as a surrogate measure for ICP.
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Affiliation(s)
- Ji-Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 Republic of Korea
| | - Hyungseok Seo
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 Republic of Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 Republic of Korea
| | - Joohyun Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 Republic of Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736 Republic of Korea
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Abstract
OPINION STATEMENT Hepatic encephalopathy management varies depending on the acuity of liver failure. However, in patients with either acute or chronic liver failure five basic steps in management are critical: stabilization, addressing modifiable precipitating factors, lowering blood ammonia, managing elevated intracranial pressure (ICP) (if present), and managing complications of liver failure that can contribute to encephalopathy, particularly hyponatremia. Because liver failure patients are prone to a variety of other medical problems that can lead to encephalopathy (such as coagulopathy associated intracranial hemorrhage, electrolyte disarray, renal failure, hypotension, hypoglycemia, and infection), a thorough history, physical and neurologic examination is mandated in all encephalopathic liver failure patients. There should be a low threshold for brain imaging in patients with focal neurological deficits given the propensity for spontaneous intracranial hemorrhage. In patients with acute liver failure and high grade encephalopathy, identification of the etiology of acute liver failure is essential to guide treatment and antidote administration, particularly in the case of acetaminophen poisoning. Equally critical is management of elevated ICP in acute liver failure. Intracranial hypertension can be treated with hypertonic saline and/or adjustment of the dialysis bath. Placement of an intracranial monitor to guide ICP therapy is risky because of concomitant coagulopathy and remains controversial. Continuous renal replacement therapy may help lower serum ammonia, treat coexisting uremia, and improve symptoms. Liver transplantation is the definitive treatment for patients with acute liver failure and hepatic encephalopathy. In patients with chronic hepatic encephalopathy, lactulose and rifaxamin remain a mainstay of therapy. In these patients, it is essential to identify reversible causes of hepatic encephalopathy such as increased ammonia production and/or decreased clearance (eg, infection, GI bleed, constipation, hypokalemia, dehydration). Chronic hyponatremia should be managed by gradual sodium correction of no more than 8‒12 meq/L per day to avoid central myelinolysis syndrome. Free water restriction and increased dietary sodium are reasonable, cost effective treatment options. Many emerging therapies, both pharmacologic and interventional, are currently being studied to improve management of hepatic encephalopathy.
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Merceron S, Geeraerts T. Ocular sonography for the detection of raised intracranial pressure. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.3.5.497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Seo H, Kim YK, Shin W, Hwang G. Ultrasonographic Optic Nerve Sheath Diameter Is Correlated With Arterial Carbon Dioxide Concentration During Reperfusion in Liver Transplant Recipients. Transplant Proc 2013; 45:2272-6. [DOI: 10.1016/j.transproceed.2012.12.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 12/30/2012] [Indexed: 02/09/2023]
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Messerer M, Berhouma M, Messerer R, Dubourg J. [Interest of optic nerve sheath diameter ultrasonography in dectecting non-invasively raised intracranial pressure]. Neurochirurgie 2013; 59:55-9. [PMID: 23523218 DOI: 10.1016/j.neuchi.2013.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Revised: 01/06/2013] [Accepted: 02/02/2013] [Indexed: 10/27/2022]
Abstract
Intracranial hypertension is an emergency suspected from clinical symptoms, imaging data and ophthalomologic signs. Intracranial hypertension is confirmed by invasive intracranial monitoring, which is the gold standard technique to measure intracranial pressure (ICP). Because of complications, hemorrhage or infection, non-invasive methods have been developed such as neuroimaging, transcranial Doppler sonography and optic nerve sheath diameter (ONSD) ultrasonography. We have reviewed ONSD technique that detects intracranial hypertension related volume variations of subarachnoid space along the retro bulbar segment of the optic nerve. Technique, indications and prospects are discussed.
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Affiliation(s)
- M Messerer
- Service de neurochirurgie, département des neurosciences cliniques, centre hospitalier universitaire Vaudois, Lausanne, Suisse
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Krishnamoorthy V, Beckmann K, Mueller M, Sharma D, Vavilala MS. Perioperative estimation of the intracranial pressure using the optic nerve sheath diameter during liver transplantation. Liver Transpl 2013; 19:246-9. [PMID: 23225529 DOI: 10.1002/lt.23591] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 12/03/2012] [Indexed: 02/06/2023]
Abstract
An elevation of the intracranial pressure (ICP) secondary to cerebral edema is a major contributor to morbidity and mortality in acute liver failure. In addition, invasive ICP monitoring in this setting is controversial because coagulopathy predisposes patients to hemorrhagic complications. In this case report, we describe the novel use of optic nerve sheath diameter monitoring as a noninvasive modality for checking for acute elevations in ICP in this setting. Because of the merits of rapidly evolving ultrasound technologies, this may serve as a safe method for improving patient care in this setting.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
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Dubost C, Motuel J, Geeraerts T. [Non-invasive evaluation of intracranial pressure: how and for whom?]. ACTA ACUST UNITED AC 2012; 31:e125-32. [PMID: 22683401 DOI: 10.1016/j.annfar.2012.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The invasive monitoring of intracranial pressure is useful in circumstances associated with high-risk of raised intracranial pressure. However the placement of intracranial probe is not always possible and non-invasive assessment of intracranial pressure may be useful, particularly in case of emergencies. Transcranial Doppler measurements allow the estimation of perfusion pressure with the pulsatility index. Recently, new ultrasonographic methods of cerebral monitoring have been developed: the diameter of the optic nerve sheath diameter, a surrogate marker of raised intracranial pressure and the estimation of median shift line deviation.
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Affiliation(s)
- C Dubost
- Département d'anesthésie-réanimation, HIA Val-de-Grâce, 74, boulevard de Port-Royal, 75230 Paris 05, France
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Hansen HC, Lagrèze W, Krueger O, Helmke K. Dependence of the optic nerve sheath diameter on acutely applied subarachnoidal pressure - an experimental ultrasound study. Acta Ophthalmol 2011; 89:e528-32. [PMID: 21518306 DOI: 10.1111/j.1755-3768.2011.02159.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine the distensibility and elastic characteristics of the optic nerve sheath for development of a basic understanding of ultrasound studies aimed to measure optic nerve sheath diameter (ONSD) for detection of acutely elevated intracranial pressure (ICP). METHODS Isolated human optic nerves preparations obtained from autopsies were submitted to predefined pressure alterations, and consecutive changes in ONSD were measured by B-scan ultrasound under defined conditions. RESULTS Following submission to pressure, the diameter of the nerve sheath increased up to 140% of its baseline value. The increase (mean 1.97 mm, SD 0.52 mm) corresponded to the magnitude of pressure steps measured in the perineural subarachnoidal space (SAS). Similarly, the ONSD declined in each of the preparations within a few minutes after the optic nerve was decompressed. However, it did not reach its baseline value again when pressure loads of 45-55 mmHg or more had been applied. CONCLUSIONS The elasticity of the anterior sheath of the optic nerve is sufficient for the detection of pressure changes in the SAS especially for upward pressure steps. This is basically important for the application of clinical monitoring of the sheath diameter to facilitate the identification of patients with elevated ICP non-invasively (screening). However, further implementation of this procedure in neurointensive care and emergency medicine has to consider that the sheath diameter reversibility may be impaired after episodes of prolonged intracranial hypertension and a model for hysteresis is proposed.
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Affiliation(s)
- Hans-Christian Hansen
- Department of Neurology & Psychiatry, Friedrich-Ebert-Hospital Neumuenster/University of Hamburg, Hamburg, Germany.
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Abstract
The rapid diagnosis of intracranial hypertension is urgently needed for therapeutic reasons in various clinical settings. This can rarely be achieved without invasive procedures such as intracranial pressure (ICP) monitoring or neuroimaging. The optic nerve is surrounded by cerebrospinal fluid (CSF) and dura mater, which forms the optic nerve sheath (ONS). Because of the connection with the intracranial subarachnoid space, ONS diameter (ONSD) is influenced by CSF pressure variations. Bedside ultrasonographic measurement of ONSD has been proposed as a non-invasive and reliable means to detect raised ICP in neurocritically ill patients. In several studies, it proves to have a good correlation with the direct measurement of ICP and a low interobserver variability. However, no general consensus exists over the upper normal ONSD limit. We performed a review of the literature on the use of the ultrasonography of the optic nerve in the evaluation of patients with suspected intracranial hypertension. The aim of this review is to describe the technique and to assess the validity of this diagnostic method.
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Affiliation(s)
- R Moretti
- Department of Anesthesia and Critical Care, Ospedale SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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State-of-the-Art management and Monitoring of Brain Edema and Intracranial Hypertension in Fulminant Hepatic Failure. A Proposed Algorithm. BRAIN EDEMA XIV 2010; 106:311-4. [DOI: 10.1007/978-3-211-98811-4_58] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Moretti R, Pizzi B, Cassini F, Vivaldi N. Reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial hemorrhage. Neurocrit Care 2009; 11:406-10. [PMID: 19636971 DOI: 10.1007/s12028-009-9250-8] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The aim of our study is to confirm the reliability of optic nerve ultrasound as a method to detect intracranial hypertension in patients with spontaneous intracranial hemorrhage, to assess the reproducibility of the measurement of the optic nerve sheath diameter (ONSD), and to verify that ONSD changes concurrently with intracranial pressure (ICP) variations. METHODS Sixty-three adult patients with subarachnoid hemorrhage (n = 34) or primary intracerebral hemorrhage (n = 29) requiring sedation and invasive ICP monitoring were enrolled in a 10-bed multivalent ICU. ONSD was measured 3 mm behind the globe through a 7.5-MHz ultrasound probe. Mean binocular ONSD was used for statistical analysis. ICP values were registered simultaneously to ultrasonography. Twenty-eight ONSDs were measured consecutively by two different observers, and interobserver differences were calculated. Twelve coupled measurements were taken before and within 1 min after cerebrospinal fluid (CSF) drainage to control elevated ICP. RESULTS Ninety-four ONSD measurements were analyzed. 5.2 mm proved to be the optimal ONSD cut-off point to predict raised ICP (>20 mmHg) with 93.1% sensitivity (95% CI: 77.2-99%) and 73.85% specificity (95% CI: 61.5-84%). ONSD-ICP correlation coefficient was 0.7042 (95% CI for r = 0.5850-0.7936). The median interobserver ONSD difference was 0.25 mm. CSF drainage to control elevated ICP caused a rapid and significant reduction of ONSD (from 5.89 ± 0.61 to 5 ± 0.33 mm, P < 0.01). CONCLUSION Our investigation confirms the reliability of optic nerve ultrasound as a non-invasive method to detect elevated ICP in intracranial hemorrhage patients. ONSD measurements proved to have a good reproducibility. ONSD changes almost concurrently with CSF pressure variations.
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Affiliation(s)
- Riccardo Moretti
- Department of Anesthesia and Critical Care, Ospedale SS Antonio e Biagio e Cesare Arrigo, via Venezia 16, 15100 Alessandria, Italy.
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Geeraerts T, Dubost C. Theme: Neurology - Optic nerve sheath diameter measurement as a risk marker for significant intracranial hypertension. Biomark Med 2009; 3:129-37. [DOI: 10.2217/bmm.09.6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Raised intracranial pressure (ICP) is a frequent condition in many medical and surgical situations and is often difficult to detect. Noninvasive estimates of raised ICP are of interest to allow rapid detection of significant intracranial hypertension. In the anterior part of the optic nerve, the sheath is distensible and can inflate in the case of raised pressure in the cerebrospinal fluid. Measurement of optic nerve sheath diameter using ocular sonography or MRI has been shown to correctly estimate the risk of raised ICP in various settings, including traumatic brain injury. Ocular sonography is simple, rapid, noninvasive and can be performed at the patient’s bedside, but it requires training and experience. The cut-off value for ICP greater than 20 mmHg is 5.8 mm, with a 90% probability of correct diagnosis. When raised ICP is suspected, but invasive ICP monitoring cannot be used or is not clearly recommended, this estimation of the risk of raised ICP may be of great clinical value, aiding in the detection of patients at risk of raised ICP.
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Affiliation(s)
- Thomas Geeraerts
- Département d’Anesthésie-Réanimation, Centre Hospitalier Universitaire Antoine Béclère, 157 rue de la Porte de Trivaux, BP 405, 92141 Clamrt Cedex, France
- AP-HP & University Paris-Sud, University Hospital Antoine Béclère, Department of Anesthesiology & Critical Care, Clamart, France
| | - Clément Dubost
- AP-HP & University Paris-Sud, University Hospital Antoine Béclère, Department of Anesthesiology & Critical Care, Clamart, France
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Optic nerve ultrasound for detection of intracranial hypertension in intracranial hemorrhage patients: confirmation of previous findings in a different patient population. J Neurosurg Anesthesiol 2009; 21:16-20. [PMID: 19098619 DOI: 10.1097/ana.0b013e318185996a] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bedside ultrasonographic measurement of optic nerve sheath diameter (ONSD) has been proposed as a method to detect raised intracranial pressure (ICP) in various clinical settings. The aim of our study is to evaluate the use of ultrasonography in the case of intracranial hemorrhage and to assess the validity of the conventional cut-off point of 5 mm. A prospective blind observational study in a 10-bed multivalent intensive care unit was carried out by enrolling 53 adult patients with primary intracerebral hemorrhage (23) or subarachnoid hemorrhage (30), requiring ICP monitoring, sedation, and mechanical ventilation and 53 control patients with no intracranial pathology, requiring sedation and mechanical ventilation. ONSD was measured 3 mm behind the globe by using a 7.5 MHz linear ultrasound probe. Mean binocular ONSD was used for data analysis. Nineteen patients proved to have raised ICP (>20 mm Hg). In this group, ONSD at admission was 6.2+/-0.6 mm, a significantly higher value than in low ICP patients (P<0.01). In the 34 patients with ICP <20 mm Hg, ONSD was 5.0+/-0.5 mm, and it resulted not significantly different from ONSD in the control group (4.9+/-0.4 mm). A receiver operator characteristic curve was constructed and an ONSD threshold of 5.2 mm as a predictor of ICP >20 mm Hg proved to be an attractive combination of sensitivity and specificity (94% and 76%, respectively). In conclusion, our study confirms the utility of optic nerve ultrasound in the early diagnostic evaluation of patients with known or suspected intracranial hemorrhage.
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Geeraerts T, Newcombe VFJ, Coles JP, Abate MG, Perkes IE, Hutchinson PJA, Outtrim JG, Chatfield DA, Menon DK. Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R114. [PMID: 18786243 PMCID: PMC2592740 DOI: 10.1186/cc7006] [Citation(s) in RCA: 192] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 08/18/2008] [Accepted: 09/11/2008] [Indexed: 12/18/2022]
Abstract
Introduction The dural sheath surrounding the optic nerve communicates with the subarachnoid space, and distends when intracranial pressure is elevated. Magnetic resonance imaging (MRI) is often performed in patients at risk for raised intracranial pressure (ICP) and can be used to measure precisely the diameter of optic nerve and its sheath. The objective of this study was to assess the relationship between optic nerve sheath diameter (ONSD), as measured using MRI, and ICP. Methods We conducted a retrospective blinded analysis of brain MRI images in a prospective cohort of 38 patients requiring ICP monitoring after severe traumatic brain injury (TBI), and in 36 healthy volunteers. ONSD was measured on T2-weighted turbo spin-echo fat-suppressed sequence obtained at 3 Tesla MRI. ICP was measured invasively during the MRI scan via a parenchymal sensor in the TBI patients. Results Measurement of ONSD was possible in 95% of cases. The ONSD was significantly greater in TBI patients with raised ICP (>20 mmHg; 6.31 ± 0.50 mm, 19 measures) than in those with ICP of 20 mmHg or less (5.29 ± 0.48 mm, 26 measures; P < 0.0001) or in healthy volunteers (5.08 ± 0.52 mm; P < 0.0001). There was a significant relationship between ONSD and ICP (r = 0.71, P < 0.0001). Enlarged ONSD was a robust predictor of raised ICP (area under the receiver operating characteristic curve = 0.94), with a best cut-off of 5.82 mm, corresponding to a negative predictive value of 92%, and to a value of 100% when ONSD was less than 5.30 mm. Conclusions When brain MRI is indicated, ONSD measurement on images obtained using routine sequences can provide a quantitative estimate of the likelihood of significant intracranial hypertension.
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Affiliation(s)
- Thomas Geeraerts
- University Division of Anaesthesia and Wolfson Brain Imaging Center, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 2QQ, UK.
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Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 2008; 34:2062-7. [PMID: 18509619 DOI: 10.1007/s00134-008-1149-x] [Citation(s) in RCA: 269] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2008] [Accepted: 05/02/2008] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess the relationship between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in neurocritical care patients. DESIGN Prospective, observational study. SETTING Surgical critical care unit, level 1 trauma center. PATIENTS A total number of 37 adult patients requiring sedation and ICP monitoring after severe traumatic brain injury, subarachnoid hemorrhage, intracranial hematoma, or stroke. MEASUREMENTS AND MAIN RESULTS Optic nerve sheath diameter was measured with a 7.5 MHz linear ultrasound probe. ICP was measured invasively via a parenchymal device. Simultaneous measurements were performed at least once a day during the first 2 days after ICP insertion and in cases of acute changes. There was a significant relationship between ONSD and ICP (78 simultaneous measures, r = 0.71, P < 0.0001). Changes in ICP were strongly correlated with changes in ONSD (39 measures, r = 0.73, P < 0.0001). Enlarged ONSD was a suitable predictor of elevated ICP (>20 mmHg) (area under ROC curve = 0.91). When ONSD was less than 5.86 mm, the negative likehood ratio for raised ICP was 0.06. CONCLUSION In sedated neurocritical care patients, non-invasive sonographic measurements of ONSD are correlated with invasive ICP, and the probability to have raised ICP if ONSD is less than 5.86 mm is very low. This method could be used as a screening test when raised ICP is suspected.
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Ocular sonography in patients with raised intracranial pressure: the papilloedema revisited. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:150. [PMID: 18495051 PMCID: PMC2481446 DOI: 10.1186/cc6893] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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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Soldatos T, Karakitsos D, Chatzimichail K, Papathanasiou M, Gouliamos A, Karabinis A. Optic nerve sonography in the diagnostic evaluation of adult brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R67. [PMID: 18477382 PMCID: PMC2481450 DOI: 10.1186/cc6897] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 04/16/2008] [Accepted: 05/13/2008] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The optic nerve sheath diameter (ONSD) may be increased in brain-injured patients, especially children, with intracranial hypertension. We investigated whether measurements of ONSD correlated with simultaneous noninvasive and invasive measurements of the intracranial pressure (ICP) in brain-injured adults. METHODS Seventy-six critical care patients (58 males; 47 +/- 18 years old) were included in the study. Fifty patients suffered from brain injury, whereas 26 had no intracranial pathology and served as control individuals. Initially, brain-injured patients were evaluated clinically (Glasgow Coma Scale) and using a semiquantitative (I to VI) neuroimaging scale (Marshall Scale). Thereafter, the patients were divided into those with moderate (Marshall Scale = I and Glasgow Coma Scale > 8 [n = 18]) and severe (Marshall Scale = II to VI and Glasgow Coma Scale < or =8 [n = 32]) brain injury. All patients underwent noninvasive measurement of the ICP (estimated ICP) by transcranial Doppler sonography, and synchronous ONSD measurements by optic nerve sonography. Finally, invasive ICP measurement using an intraparenchymal catheter was performed in patients with severe brain injury. RESULTS ONSD and estimated ICP were both significantly increased (6.1 +/- 0.7 mm and 26.2 +/- 8.7 mmHg, respectively; P < 0.0001) in patients with severe brain injury as compared with patients with moderate brain injury (4.2 +/- 1.2 mm and 12.0 +/- 3.6 mmHg) and compared with control individuals (3.6 +/- 0.6 mm and 10.3 +/- 3.1 mmHg). Furthermore, in patients with severe brain injury the ONSD measurements were strongly correlated with estimated ICP values (r = 0.80, P < 0.0001) as well as with the neuroimaging scale results (r = 0.82, P < 0.001). In the patients with severe brain injury, ONSD measurements correlated with invasive ICP values (r = 0.68, P = 0.002). The best cut-off value of ONSD for predicting elevated ICP was 5.7 mm (sensitivity = 74.1% and specificity = 100%). CONCLUSION ONSD measurements correlate with noninvasive and invasive measurements of the ICP, and with head computed tomography scan findings in brain-injured adults. Hence, optic nerve sonography may serve as an additional diagnostic tool that could alert clinicians to the presence of elevated ICP, whenever invasive ICP evaluation is contraindicated and/or is not available. This trial is International Standard Randomised Controlled Trial Number registered (ISRCTN 91941687).
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Affiliation(s)
- Theodoros Soldatos
- Second Department of Radiology, Attikon University Hospital, 1 Rimin st, 124 62, Athens, Greece
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Rempf C, Helmke K, Gottschalk A, Farokhzad F, Burmeister MA. Intraoperative anisocoria in a child during renal transplantation. Acta Anaesthesiol Scand 2008; 52:307-9. [PMID: 18005382 DOI: 10.1111/j.1399-6576.2007.01505.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Anisocoria during anaesthesia may indicate a serious neurological condition. Assessment by physical examination and diagnostic imaging is limited during surgery and anaesthesia. We report a case of a boy undergoing renal transplantation, who suffered from anisocoria during general anaesthesia. A transcranial sonography was performed, showing no intracranial pathology. However, retinal hypoperfusion detected with orbital doppler sonography was a plausible explanation for anisocoria.
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Affiliation(s)
- C Rempf
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Knappschaftskrankenhaus Bochum Langendreer, University hospital, Bochum, Germany.
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Geeraerts T, Launey Y, Martin L, Pottecher J, Vigué B, Duranteau J, Benhamou D. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med 2007; 33:1704-11. [PMID: 17668184 DOI: 10.1007/s00134-007-0797-6] [Citation(s) in RCA: 280] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Accepted: 06/18/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE 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. DESIGN AND SETTING Prospective, blind, observational study in a surgical critical care unit, level 1 trauma center. PATIENTS AND PARTICIPANTS 31 adult patients with severe traumatic brain injury (TBI; Glasgow coma scale <or=8) requiring sedation and ICP monitoring, and 31 control patients without brain injury requiring sedation. MEASUREMENTS AND RESULTS ONSD was measured with a 7.5-MHz linear ultrasound probe. Two TBI groups were defined on the basis of ICP profile. If ICP exceeded 20 mmHg for more than 30 min in the first 48 h (before any specific treatment), patients were considered to have high ICP; if not, they had normal ICP. The largest ONSD value (the highest value for the right and left eye) was significantly higher in high ICP patients (6.3 +/-0.6 vs. 5.1+/-0.7 mm in normal ICP patients and 4.9+/-0.3mm in control patients). There was a significant relationship between the largest ONSD and ICP at admission (r=0.68). The largest ONSD was a suitable predictor of high ICP (area under ROC curve 0.96). When ONSD was under 5.7 mm, the sensitivity and negative predictive values for high ICP were 100%. CONCLUSIONS In the early posttraumatic period, ocular ultrasound scans may be useful for detecting high ICP after severe TBI.
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Affiliation(s)
- Thomas Geeraerts
- Department of Anesthesiology and Critical Care Medicine, Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Faculty of Medicine, University of Paris-Sud, Le Kremlin Bicêtre, 94275, Paris, France.
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Gottlieb A, DeBoer KR. Brain preservation during orthotopic liver transplantation in a patient with acute liver failure and severe elevation of intracranial pressure. J Gastrointest Surg 2005; 9:888-90. [PMID: 16137579 DOI: 10.1016/j.gassur.2005.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 06/05/2005] [Indexed: 01/31/2023]
Affiliation(s)
- Alexandru Gottlieb
- Department of General Anesthesiology, Section of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Nakanishi K, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M, Hirano T, Hirayama Y, Moriguchi T, Watanabe E, Nitta M. Intracranial Pressure Monitoring in Patients with Fulminant Hepatic Failure Treated with Plasma Exchange and Continuous Hemodiafiltration. Blood Purif 2005; 23:113-8. [PMID: 15640603 DOI: 10.1159/000083205] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS To study the influence of our artificial liver support (ALS) on intracranial pressure (ICP) and to evaluate the significance of ICP monitoring in fulminant hepatic failure (FHF) patients treated with ALS. METHODS ICP was measured in 13 consecutive FHF patients treated with ALS. Maximum value in ICP every day was employed as ICPmax of the day. We analyzed the correlation: (a) between ICPmax and consciousness level; (b) between ICP and colloid osmotic pressure (COP), and (c) between ICP and PaCO2. RESULTS ICP in 11 patients of 13 was controlled < 20 mm Hg through our ALS. A significant positive correlation between ICPmax and consciousness level was found (p < 0.01). Although there was a significantly negative correlation between ICP and COP (p < 0.001), there was no correlation between ICP and PaCO2. CONCLUSIONS We conclude that our ALS does not have any adverse effects on ICP and that ICP monitoring is one of the inevitable monitorings in the management of FHF.
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Affiliation(s)
- Kazuya Nakanishi
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Chuo, Japan.
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Saito M, Olby NJ, Spaulding K, Muñana K, Sharp NJH. RELATIONSHIP AMONG BASILAR ARTERY RESISTANCE INDEX, DEGREE OF VENTRICULOMEGALY, AND CLINICAL SIGNS IN HYDROCEPHALIC DOGS. Vet Radiol Ultrasound 2003; 44:687-94. [PMID: 14703252 DOI: 10.1111/j.1740-8261.2003.tb00532.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Forty-four transcranial Doppler ultrasound studies were performed in 36 dogs. The ratio of the height of the ventricle to the height of the brain (VB ratio) was calculated to determine the severity of ventriculomegaly. Resistance index (RI) was calculated from Doppler measurements of the blood flow velocity in the basilar artery and neurologic signs were scored on a scale of 0 to 3. Based on clinical and ultrasonographic findings, dogs were divided into four groups (normal controls, asymptomatic hydrocephalus, symptomatic hydrocephalus, and other intracranial disease). RI and VB ratio were compared between the groups of dogs and compared with neurologic signs in hydrocephalic dogs. RI ranged from 0.50 to 0.81 (mean, 0.68). Resistance index was significantly higher in dogs with symptomatic hydrocephalus and other intracranial disease when compared with the other two groups. The degree of ventriculomegaly was significantly higher in dogs with symptomatic hydrocephalus than the other groups, but there was substantial overlap between asymptomatic and symptomatic hydrocephalus groups. Combining measurements of VB ratio and RI allowed detection of symptomatic hydrocephalus with a sensitivity of 77% and a specificity of 94%. The severity of neurological signs was significantly correlated with RI and with VB ratio in hydrocephalic dogs, and in dogs evaluated on more than one occasion, changes in neurologic status were accompanied by changes in RI but not in VB ratio. All asymptomatic hydrocephalic dogs with a VB ratio of greater than 60% eventually developed neurologic signs. Our results suggest that ultrasonographic measurement of VB ratio and basilar artery RI may allow identification of dogs with symptomatic hydrocephalus or dogs that are at risk of developing symptomatic hydrocephalus. Repeated RI measurements are a useful means of monitoring dogs with a variety of intracranial diseases.
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Affiliation(s)
- Miyoko Saito
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27606, USA
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Sizer E, Wendon J, Bernal W. Acute Liver Failure in the ICU. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
The brain is sensitive to changes in substrate delivery. In neurologically critically ill patients (e.g., those with head injury, subarachnoid hemorrhage, or stroke), interruption of this supply causes ischemic brain damage and thus impairs the outcome. To prevent, detect, and treat these ischemic events as soon as possible, the cerebral blood flow is continuously monitored, its coupling or not with the consumption of oxygen and so forth, and the detected derangements of normal physiology. Intracranial pressure and cerebral perfusion pressure are two parameters that often reflect ischemic events, and thus it is mandatory to continuously measure them. To better assess cerebral hemodynamics, jugular bulb oxymetry and brain pressure tissue oxygen monitoring are two neuromonitoring techniques that allow for a better understanding of the balance between oxygen supply and consumption, and therefore are useful in directing therapy. Transcranial Doppler ultrasonography is a noninvasive technique with the same purpose but with less clinical relevance. The new neuromonitoring technique, microdialysis, is useful for understanding the mechanisms involved in brain ischemia. However, it is clear that the physician who interprets the measurements given by devices and the clinical data (e.g., temperature, glycemia) is still the cornerstone in the management of neurologically critically ill patients.
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