Decreased diameter of the optic nerve sheath associated with CSF hypovolemia

Optic Nerve Sheath MR Imaging Measurements in Patients with Orthostatic Headaches and Normal Findings on Conventional Imaging Predict the Presence of an Underlying CSF-Venous Fistula

BACKGROUND AND PURPOSE

Spontaneous spinal CSF leaks typically cause orthostatic headache, but their detection may require specialized and invasive spinal imaging. We undertook a study to determine the value of simple optic nerve sheath MR imaging measurements in predicting the likelihood of finding a CSF-venous fistula, a type of leak that cannot be detected with routine spine MR imaging or CT myelography, among patients with orthostatic headache and normal conventional brain and spine imaging findings.

MATERIALS AND METHODS

This cohort study included a consecutive group of patients with orthostatic headache and normal conventional brain and spine imaging findings who underwent digital subtraction myelography under general anesthesia to look for spinal CSF-venous fistulas.

RESULTS

The study group consisted of 93 patients (71 women and 22 men; mean age, 47.5 years; range, 17-84 years). Digital subtraction myelography demonstrated a CSF-venous fistula in 15 patients. The mean age of these 8 women and 7 men was 56 years (range, 23-83 years). The mean optic nerve sheath diameter was 4.0 mm, and the mean perioptic subarachnoid space was 0.5 mm in patients with a CSF-venous fistula compared with 4.9 and 1.2 mm, respectively, in patients without a fistula (P < .001). Optimal cutoff values were found at 4.4 mm for optic nerve sheath diameter and 1.0 mm for the perioptic subarachnoid space. Fistulas were detected in about 50% of patients with optic nerve sheath diameter or perioptic subarachnoid space measurements below these cutoff values compared with <2% of patients with optic nerve sheath diameter or perioptic subarachnoid space measurements above these cutoff values. Following surgical ligation of the fistula, optic nerve sheath diameter increased from 4.0 to 5.3 mm and the perioptic subarachnoid space increased from 0.5 to 1.2 mm (P < .001).

CONCLUSIONS

Concerns about a spinal CSF leak should not be dismissed in patients with orthostatic headache when conventional imaging findings are normal, and simple optic nerve sheath MR imaging measurements can help decide if more imaging needs to be performed in this patient population.

Association between Optic Nerve Sheath Diameter and Lamina Cribrosa Morphology in Normal-Tension Glaucoma

(1) Background: To compare optic nerve sheath diameter (ONSD) in normal-tension glaucoma (NTG) and healthy eyes and to investigate the association between ONSD and lamina cribrosa (LC) morphology. (2) Methods: This cross-sectional study included 69 NTG eyes and 69 healthy eyes matched for age, axial length, and intraocular pressure. The LC curvature index (LCCI) was measured from horizontal Cirrus HD-OCT B-scan images from five uniformly divided positions vertically of the optic nerve. The average LCCI was defined as the mean of the measurements at these five locations. ONSD was measured as the width of the optic nerve sheath at the site perpendicular 3 mm behind the posterior globe. LCCI and ONSD were compared in eyes with NTG and healthy eyes. The clinical factors that could affect LCCI were analyzed. (3) Results: NTG eyes had significantly smaller mean ONSD (4.55 ± 0.69 mm vs. 4.97 ± 0.58 mm, p < 0.001) and larger average LCCI (11.61 ± 1.43 vs. 7.58 ± 0.90, p < 0.001) than matched healthy control eyes. LCCI was significantly correlated with smaller ONSD, higher intraocular pressure, thinner global retinal nerve fiber thickness, and worse visual field loss in all subjects (all Ps ≤ 0.022). (4) Conclusions: NTG eyes had smaller ONSD and greater LCCI than healthy control eyes. In addition, a negative correlation was observed between ONSD and LCCI. These findings suggest that cerebrospinal fluid pressure, which ONSD indirectly predicts, may affect LC configuration. Changes in the retrolaminar compartment may play a role in glaucoma pathogenesis.

Ultrasonographic optic nerve sheath diameter as a noninvasive marker for intracranial hypotension

Background:

Invasive intracranial pressure (ICP) can result in complications, pain, or even aggravate intracranial hypotension (IH) or headache in patients with IH.

Objective:

To investigate whether ultrasonographic measurements of optic nerve sheath diameter (ONSD) could serve as a noninvasive IH marker.

Methods:

Ultrasonographic ONSD was measured prior to lumbar puncture (LP) and ONSD measurements compared to LP’s opening pressure. We analyzed correlations between ONSD and ICP and determined the optimal ONSD cut-off point for IH. According to their LP on admission, patients were divided into three groups: IH group, normal ICP group, and elevated ICP group. Correlations between ONSD and ICP were analyzed using Pearson’s correlation. A receiver operating characteristic (ROC) curve was generated to determine the optimal cut-off point for IH.

Results:

In total, 136 subjects (75 men, 55.1% men) were included, and 1088 ONSDs were measured. The ONSD of the IH group (2.96 ± 0.15 mm) was significantly lower than that of the normal (3.59 ± 0.33 mm) and elevated ICP groups (4.90 ± 0.42 mm, p < 0.001). There was a significant difference in ONSD within all groups (p < 0.001), and the differences between the two groups were also statistically significant. ONSD and ICP values were strongly correlated, with an r = 0.952 (95% confidence interval [CI]: 0.924–0.969; p < 0.001). After adjusting for age, diastolic blood pressure, systolic blood pressure, body mass index, waistline, and head circumference, ONSD was positively associated with ICP. ROC curve analysis revealed an area under the curve of 0.990 (95% CI: 0.975–1.000). The ONSD cut-off point for identifying decreased opening pressure on LP was 3.15 mm, with 98.3% sensitivity and 91.7% specificity.

Conclusions:

Ultrasonographic ONSD may be a noninvasive, valuable, and easy-to-perform bedside technology for evaluating IH.

Early Detection of Central Nervous System Relapse of Pediatric Leukemia with Measurement of Optic Nerve Sheath Diameter on MRI

BACKGROUND

Leukemia is the most common pediatric malignancy. Central Nervous System (CNS) is the most frequently involved extramedullary location at diagnosis and at relapse.

OBJECTIVE

To determine if Magnetic Resonance Imaging (MRI) findings of optic nerves should contribute to early detection of CNS relapse in pediatric leukemia.

METHODS

Twenty patients (10 boys, 10 girls; mean age 8,3 years, range 4-16 years) with proven CNS relapse of leukemia followed up between 2009 and 2017 in our institution were included. Orbital MRI exams performed before and during CNS relapse were reviewed retrospectively. Forty optic nerves with Optic Nerve Sheaths (ONS) and Optic Nerve Heads (ONH) were evaluated on fat-suppressed T2-weighted TSE axial MR images. ONS diameter was measured from the point 10 mm posterior to the globe. ONS distension and ONH configuration were graded as 0, 1 and 2.

RESULTS

Before CNS relapse, right mean ONS diameter was 4.52 mm and left was 4.61 mm which were 5.68 mm and 5.66 mm respectively during CNS relapse showing a mean increase of 25% on right and 22% on left. During CNS relapse, ONS showed grade 0 distension in 15%, grade 1 in 60%, grade 2 in 25% and ONH demonstrated grade 0 configuration in 70%, grade 1 in 25% and grade 2 in 5% of the patients.

CONCLUSION

MRI findings of optic nerves may contribute to diagnose CNS relapse by demonstrating elevated intracranial pressure in children with leukemia.

Postural changes in optic nerve and optic nerve sheath diameters in postural orthostatic tachycardia syndrome and spontaneous intracranial hypotension: A cohort study

Background

Postural orthostatic tachycardia syndrome is a disorder of the autonomic nervous system. Approximately 30% of patients experience orthostatic headaches. Orthostatic headaches also are a hallmark symptom in spontaneous intracranial hypotension. While the cause of orthostatic headaches in spontaneous intracranial hypotension can be linked to the cerebrospinal fluid loss at the spinal level and consecutively reduced intracranial pressure in the upright position, the cause of orthostatic headaches in postural orthostatic tachycardia syndrome still remains unknown. The present study examined orthostatic changes of intracranial pressure using dynamic ultrasound of the optic nerve and optic nerve sheath diameter in postural orthostatic tachycardia syndrome, spontaneous intracranial hypotension and healthy subjects.

Methods

Data was obtained from postural orthostatic tachycardia syndrome patients with (n = 7) and without orthostatic headaches (n = 7), spontaneous intracranial hypotension patients (n = 5) and healthy subjects (n = 8). All participants underwent high-resolution transorbital ultrasound in the supine and upright position to assess optic nerve and optic nerve sheath diameter.

Results

Group differences were found in percentage deviations when changing position of optic nerve sheath diameter (p < 0.01), but not regarding the optic nerve diameter. Pairwise comparisons indicated differences in optic nerve sheath diameter only between spontaneous intracranial hypotension and the other groups. No differences were found between postural orthostatic tachycardia syndrome patients with and without orthostatic headaches.

Conclusion

This study shows that the size of the optic nerve sheath diameter dynamically decreases during orthostatic stress in spontaneous intracranial hypotension, but not in postural orthostatic tachycardia syndrome with or without orthostatic headaches, which indicates different underlying causes.

Use of neuroimaging measurements of optic nerve sheath diameter to assess intracranial pressure in craniosynostosis

PURPOSE

This study aims to evaluate accuracy of optic nerve sheath diameter (ONSD) measurements obtained by magnetic resonance imaging (MRI) in patients with craniosynostosis (CS) for detection of high intracranial pressure (ICP) and to correlate MRI-derived ONSD measurements with those obtained by computed tomography (CT) scans in CS patients.

METHODS

A retrospective review was conducted on CS patients who had MRI- and age-matched controls with normal MRI. Diagnosis of intracranial hypertension was based on presence of papilledema, direct ICP monitoring, and/or lumbar puncture. The search also included patients with MRI and CT done within 30 days apart. ONSDs were measured 3 mm behind the globe on both modalities.

RESULTS

The study identified 56 CS patients (mean age 3.8 ± 3.47 years) and 49 controls (mean age 3.7 ± 3.62 years). Mean ONSD in patients with high ICP was significantly higher than in patients without high ICP (P = 0.0001) and in controls (P < 0.0001). The optimal ONSD threshold for predicting raised ICP in patients >1 year old was 6 mm (71.4% sensitivity, 89.7% specificity). Nineteen patients with 38 single-eye MRI/CT pairs were identified. Substantial agreement between both modalities resulted (r = 0.959, 95% CI 0.923-0.978), and Bland and Altman Plot analysis showed that 95% of measurements fell within limits of agreement (1.96 SD; ± 0.6 mm).

CONCLUSION

In CS patients, ONSD measured by MRI represent indirect non-invasive means of ICP assessment. Both MRI and CT measurements of ONSD gave comparable results, and the use of CT-derived ONSD measurements may give some idea about ICP in CS patients.

The effect of increased intra-abdominal pressure on orbital subarachnoid space width and intraocular pressure

In accordance with the trans-lamina cribrosa pressure difference theory, decreasing the trans-lamina cribrosa pressure difference can relieve glaucomatous optic neuropathy. Increased intracranial pressure can also reduce optic nerve damage in glaucoma patients, and a safe, effective and noninvasive way to achieve this is by increasing the intra-abdominal pressure. The purpose of this study was to observe the changes in orbital subarachnoid space width and intraocular pressure at elevated intra-abdominal pressure. An inflatable abdominal belt was tied to each of 15 healthy volunteers, aged 22-30 years (12 females and 3 males), at the navel level, without applying pressure to the abdomen, before they laid in the magnetic resonance imaging machine. The baseline orbital subarachnoid space width around the optic nerve was measured by magnetic resonance imaging at 1, 3, 9, and 15 mm behind the globe. The abdominal belt was inflated to increase the pressure to 40 mmHg (1 mmHg = 0.133 kPa), then the orbital subarachnoid space width was measured every 10 minutes for 2 hours. After removal of the pressure, the measurement was repeated 10 and 20 minutes later. In a separate trial, the intraocular pressure was measured for all the subjects at the same time points, before, during and after elevated intra-abdominal pressure. Results showed that the baseline mean orbital subarachnoid space width was 0.88 ± 0.1 mm (range: 0.77-1.05 mm), 0.77 ± 0.11 mm (range: 0.60-0.94 mm), 0.70 ± 0.08 mm (range: 0.62-0.80 mm), and 0.68 ± 0.08 mm (range: 0.57-0.77 mm) at 1, 3, 9, and 15 mm behind the globe, respectively. During the elevated intra-abdominal pressure, the orbital subarachnoid space width increased from the baseline and dilation of the optic nerve sheath was significant at 1, 3 and 9 mm behind the globe. After decompression of the abdominal pressure, the orbital subarachnoid space width normalized and returned to the baseline value. There was no significant difference in the intraocular pressure before, during and after the intra-abdominal pressure elevation. These results verified that the increased intra-abdominal pressure widens the orbital subarachnoid space in this acute trial, but does not alter the intraocular pressure, indicating that intraocular pressure is not affected by rapid increased intra-abdominal pressure. This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-ONRC-14004947).

Radiographic Evidence of Occult Intracranial Hypertension in Patients with Ménière’s Disease

Objectives

(1) Describe the prevalence of radiographic signs of intracranial hypertension (ICH) in Ménière’s disease (MD) and (2) compare the prevalence of radiographic signs of ICH in MD patients managed medically to those managed surgically.

Study Design

Case-control study.

Setting

Academic neurotologic practice.

Subjects and Methods

Adult MD patients (aged ≥17 years) treated from 2011 to 2015 were reviewed. Inclusion required magnetic resonance imaging (MRI) of the head and follow-up >6 months. Patients with intracranial tumors, mass effect, trauma, previous intracranial surgery, and glaucoma were excluded. MD patients were separated by administered treatment into medical and surgical subgroups. Cochlear implant (CI) recipients served as radiographic controls. Eighty-four MD patients (46 surgical, 38 medical) and 37 CI controls were assessed. MRI measurements assessed for empty/partial sella (ES/PS), dilated/tortuous optic nerve sheath (ONS), and posterior globe flattening (PGF).

Results

Mean age was 53.8 ± 1.3 years and median body mass index (BMI) was 28.2 kg/m2. Of the patients, 64% were female and 92% were white. MRI findings in the MD cohort were as follows: ES/PS, 46.4%; ONS change, 42.8%; and PGF, 8.3%. The prevalence of ONS change was higher in MD patients than in controls (42.8% vs 13.5%, P = .003). The surgical MD group had higher prevalence of ONS change (52%) compared with the medical group (31.5%, P = .05) and controls (13.5%, P = .0004). The surgical group had a higher prevalence of ≥2 simultaneous MRI findings compared with medical MD patients (39% vs 10%, P = .01) and controls (14%, P = .01).

Conclusion

MD patients demonstrate a high prevalence of radiographic signs of ICH. MD patients who required surgery had a greater prevalence of radiographic signs of ICH compared with non-MD patients and medically managed MD patients.

Management of spontaneous intracranial hypotension - Transorbital ultrasound as discriminator

OBJECTIVE

Spontaneous intracranial hypotension (SIH) is most commonly caused by cerebrospinal fluid (CSF) leakage. Therefore, we hypothesised that patients with orthostatic headache (OH) would show decreased optic nerve sheath diameter (ONSD) during changes from supine to upright position.

METHODS

Transorbital B-mode ultrasound was performed employing a high-frequency transducer for ONSD measurements in the supine and upright positions. Absolute values and changes of ONSD from supine to upright were assessed. Ultrasound was performed in 39 SIH patients, 18 with OH and 21 without OH, and in 39 age-matched control subjects. The control group comprised 20 patients admitted for back surgery without headache or any orthostatic symptoms, and 19 healthy controls.

RESULTS

In supine position, mean ONSD (±SD) was similar in patients with (5.38±0.91 mm) or without OH (5.48±0.89 mm; p=0.921). However, in upright position, mean ONSD was different between patients with (4.84±0.99 mm) and without OH (5.53±0.99 mm; p=0.044). Furthermore, the change in ONSD from supine to upright position was significantly greater in SIH patients with OH (-0.53±0.34 mm) than in SIH patients without OH (0.05±0.41 mm; p≤0.001) or in control subjects (0.01±0.38 mm; p≤0.001; area under the curve: 0.874 in receiver operating characteristics analysis).

CONCLUSIONS

Symptomatic patients with SIH showed a significant decrease of ONSD, as assessed by ultrasound, when changing from the supine to the upright position. Ultrasound assessment of the ONSD in two positions may be a novel, non-invasive tool for the diagnosis and follow-up of SIH and for elucidating the pathophysiology of SIH.

Noninvasive intracranial pressure estimation by orbital subarachnoid space measurement: the Beijing Intracranial and Intraocular Pressure (iCOP) study

Introduction

The orbital subarachnoid space surrounding the optic nerve is continuous with the circulation system for cerebrospinal fluid (CSF) and can be visualized by using magnetic resonance imaging (MRI). We hypothesized that the orbital subarachnoid space width (OSASW) is correlated with and can serve as a surrogate for intracranial pressure (ICP). Our aim was to develop a method for a noninvasive measurement of the intracranial CSF-pressure (CSF-P) based on MRI-assisted OSASW.

Methods

The prospective observational comparative study included neurology patients who underwent lumbar CSF-P measurement and 3.0-Tesla orbital magnetic resonance imaging (MRI) for other clinical reasons. The width of the orbital subarachnoid space (OSASW) around the optic nerve was measured with MRI at 3, 9, and 15 mm behind the globe. The study population was randomly divided into a training group and a test group. After adjusting for body mass index (BMI) and mean arterial blood pressure (MABP), algorithms for the associations between CSF-P and OSASW were calculated in the training group. The algorithms were subsequently verified in the test group. Main outcome measures were the width of the orbital subarachnoid space (OSASW) and the lumbar cerebrospinal fluid pressure (CSF-P).

Results

Seventy-two patients were included in the study. In the training group, the algorithms for the associations between CSF-P and OSASW were as follows: (a) CSF-P = 9.31 × OSASW (at 3 mm) + 0.48 × BMI + 0.14 × MABP-19.94; (b) CSF-P = 16.95 × OSASW (at 9 mm) + 0.39 × BMI + 0.14 × MABP-20.90; and (c) CSF-P = 17.54 × OSASW (at 15 mm) + 0.47 × BMI + 0.13 × MABP-21.52. Applying these algorithms in the independent test group, the measured lumbar CSF-P (13.6 ± 5.1 mm Hg) did not differ significantly from the calculated MRI-derived CSF-P (OSASW at 3 mm: 12.7 ± 4.2 mm Hg (P = 0.07); at 9 mm: 13.4 ± 5.1 mm Hg (P = 0.35); and at 15 mm: 14.0 ± 4.9 mm Hg (P = 0.87)). Intraclass correlation coefficients (ICCs) were higher for the CSF-P assessment based on OSASW at 9 mm and at 15 mm behind the globe (all ICCs, 0.87) than for OSASW measurements at 3 mm (ICC, 0.80).

Conclusions

In patients with normal, moderately decreased or elevated ICP, MRI-assisted measurement of the OSASW appears to be useful for the noninvasive quantitative estimation of ICP, if BMI and MABP as contributing parameters are taken into account.

Trial registration

Clinical trial registered with the Chinese Clinical Trial Registry: ChiCTR-OCC-11001271

The role of cerebrospinal fluid pressure in glaucoma and other ophthalmic diseases: A review

Glaucoma is one of the most common causes of blindness in the world. Well-known risk factors include age, race, a positive family history and elevated intraocular pressures. A newly proposed risk factor is decreased cerebrospinal fluid pressure (CSFP). This concept is based on the notion that a pressure differential exists across the lamina cribrosa, which separates the intraocular space from the subarachnoid fluid space. In this construct, an increased translaminar pressure difference will occur with a relative increase in elevated intraocular pressure or a reduction in CSFP. This net change in pressure is proposed to act on the tissues within the optic nerve head, potentially contributing to glaucomatous optic neuropathy. Similarly, patients with ocular hypertension who have elevated CSFPs, would enjoy a relatively protective effect from glaucomatous damage. This review will focus on the current literature pertaining to the role of CSFP in glaucoma. Additionally, the authors examine the relationship between glaucoma and other known CSFP-related ophthalmic disorders.

Diagnostic value of the optic nerve sheath subarachnoid space in patients with intracranial hypotension syndrome

Object

The size of the subarachnoid space in the optic nerve sheath (ONS) on MR images is thought to reflect intracranial pressure. The diagnostic value of this space was investigated in patients with spontaneous intracranial hypotension (SIH) syndrome.

Methods

Coronal fat-saturated T2-weighted MRI of the orbit was performed in 15 patients with SIH fulfilling the diagnostic criteria for headache caused by low CSF pressure of the International Classification of Headache Disorders or the criteria for spontaneous spinal CSF leaks and intracranial hypotension. The size of the subarachnoid space in the ONS was measured in 2 slices behind the eyeballs. The images were compared before and after treatment. The CSF pressure was measured by lumbar puncture.

Results

Before treatment, the diameter of the ONS subarachnoid space ranged from 2.58 to 4.21 mm (mean 3.34 mm) and the thickness from 0 to 0.48 mm (mean 0.15 mm). Both measurements showed significant correlations with CSF opening pressure, and 8 patients had no CSF space before treatment. The size of CSF space increased in many patients after effective treatment.

Conclusions

Disappearance of the CSF space in the ONS was frequently observed in patients with SIH. This characteristic finding may be useful in the diagnosis of SIH as well as in the evaluation of treatment effectiveness.

Orbital cerebrospinal fluid space in glaucoma: the Beijing intracranial and intraocular pressure (iCOP) study

OBJECTIVE

Low cerebrospinal fluid pressure (CSF-P) may be involved in the pathogenesis of glaucoma. We measured the optic nerve subarachnoid space width (ONSASW) as a surrogate for orbital CSF-P in patients with primary open-angle glaucoma (POAG) with normal and high pressure and a control group.

DESIGN

Prospective observational study.

PARTICIPANTS

The study included 39 patients with POAG; 21 patients had normal pressure (intraocular pressure [IOP] 21 mmHg), and 18 patients had high pressure (IOP >21 mmHg); 21 subjects formed the control group.

METHODS

By using magnetic resonance imaging (MRI) with fat-suppressed fast recovery fast spin echo (FRFSE) T2-weighted sequence, we determined the ONSASW at 3, 9, and 15 mm posterior to the globe.

MAIN OUTCOME MEASURES

The ONSASW and optic nerve diameter.

RESULTS

At all 3 measurement locations of 3, 9, and 15 mm, the ONSASW was significantly (P<0.001, P<0.001, and P = 0.003, respectively) narrower in the normal-pressure group (0.67±0.16, 0.55±0.09, and 0.51±0.12 mm, respectively) than in the high-pressure group (0.93±0.21, 0.70±0.12, and 0.62±0.11 mm, respectively) or the control group (0.87±0.15, 0.67±0.07, and 0.61±0.07 mm, respectively). The high-pressure and control groups did not vary significantly at 3, 9, and 15 mm (P = 0.31, P = 0.39, and P = 0.44, respectively). At all 3 measurement locations, ONSASW was narrower in the normal-pressure group compared with the high-pressure and control groups after adjustment for optic nerve diameter (P<0.01). Correspondingly, the width of the optic nerve subarachnoid space measured at 3, 9, and 15 mm behind the globe, respectively, was significantly (all P<0.05) associated with IOP after adjustment for optic nerve diameter and visual field defect.

CONCLUSIONS

The narrower orbital optic nerve subarachnoid space in patients with POAG with normal pressure compared with high pressure suggests a lower orbital CSF-P in patients with POAG with normal pressure.

Fetal optic nerve sheath measurement as a non-invasive tool for assessment of increased intracranial pressure

OBJECTIVES

To describe the sonographic technique for assessment of the fetal optic nerve sheath and to report on three fetuses with intracranial lesions and enlarged optic nerve sheath diameter (ONSD) compared with normal controls matched for gestational age (GA).

METHODS

In this cross-sectional study ONSD was measured sonographically in three fetuses (aged 23, 24 and 35 gestational weeks) with intracranial findings associated with increased intracranial pressure (ICP; dural thrombosis and intracranial tumors) as well as 42 healthy controls matched for GA ± 1 week (aged 22-25 and 34-36 weeks). For fetal eye assessment, transabdominal and transvaginal routes and high-resolution transducers were used for optimal visualization depending on fetal position. Measurements were made using an axial view at the level of the orbits, with the fetal face positioned towards the transducer. The ONSD was measured 1.5 or 2 mm behind the papilla (depending on GA) in all fetuses. Mean ± 2 SD ONSD of controls were calculated for each GA and compared with data from the three fetuses with intracranial pathology.

RESULTS

In the 42 normal fetuses, ONSD increased from 1.2 mm at 23 weeks to 2.6 mm at 36 weeks. The measurements at 36 weeks correlated well with those observed in newborns. ONSD measurements of the three cases were above mean + 2 SD of values obtained from healthy controls at the same GA and also exceeded values of fetuses that were 1 week older.

CONCLUSIONS

Fetal ONSD measurement is feasible using a technique similar to that used in adults and children. ONSD enlargement was observed in all three fetuses with intracranial lesions and may be an early tool with which to diagnose increased ICP.

Optic nerve sheath diameter on MR imaging: establishment of norms and comparison of pediatric patients with idiopathic intracranial hypertension with healthy controls

BACKGROUND AND PURPOSE

IIH is a disorder associated with increased intracranial pressure with no clinical, laboratory, or radiologic evidence of an intracranial space-occupying lesion. The aim of this study was to establish ONSD standards of healthy pediatric subjects and compare the normal measurements with those of patients with IIH.

MATERIALS AND METHODS

One hundred fifteen MR imaging studies of children 4 months to 17 years of age were blinded and reviewed by a pediatric neuroradiologist. A total of 230 optic nerves were measured. Eighty-six MR imaging examinations were performed in apparently healthy subjects. This control group included subjects who underwent MR imaging for various reasons, and their MR imaging findings were interpreted as normal. Twenty-nine MR imaging examinations were performed in patients with documented IIH. The ONSD was measured 1 cm anterior to the optic foramina on an axial T2 sequence. For statistical analysis, both patients and controls were stratified into 4 age groups (I, 0-3 years; II, 3-6 years; III, 6-12 years; IV, 12-18 years).

RESULTS

The mean ONSD of the control group in all age groups (I, 3.1 mm; II, 3.41 mm; III, 3.55 mm; IV, 3.56 mm) was significantly smaller than the mean ONSD of patients (I, 4.35 mm; II, 4.37 mm; III, 4.25 mm; IV, 4.69 mm). A positive correlation between age and ONSD (r = 0.414, P < .01) was found in the control group.

CONCLUSIONS

According to our study, in pediatric patients with IIH, the ONSD is significantly larger than that in healthy controls regardless of age group and sex. This measurement might prove to be an auxiliary tool in the diagnosis of increased intracranial pressure in pediatric patients.

Sonographic assessment of the optic nerve sheath and transorbital monitoring of treatment effects in a patient with spontaneous intracranial hypotension: case report

OBJECTIVE

To investigate the potential of the ultrasound-based evaluation of the optic nerve sheath in a patient with spontaneous intracranial hypotension due to cervical cerebrospinal fluid (CSF) leakage.

METHODS

Repeated measurements of the optic nerve sheath diameter (ONSD) using B-mode sonography were performed before treatment initiation, during medical treatment, and during a course of repeated placement of epidural blood patches.

RESULTS

On admission, transorbital sonography revealed a decreased ONSD of 4.1 mm on the right and 4.3 mm on the left side. After 8 months of treatment with caffeine and computed tomography-guided epidural blood patches a gradual distension of the ONSD into the normal range was bilaterally observed (right: 5.2 mm; left: 5.3 mm).

CONCLUSIONS

The ultrasound-based evaluation of the optic nerve sheath may be helpful in detecting CSF hypovolemia and for determination of treatment effects. This report should be seen as a basis for future investigations on the sonographic assessment of the optic nerve sheath in diagnosis and treatment of intracranial hypotension.

Increase in optic nerve sheath diameter induced by epidural blood patch: a preliminary report

BACKGROUND

Post-dural puncture headache (PDPH) might be related to cerebrospinal fluid hypotension. Studies in brain-injured patients have shown a good relationship between optic nerve sheath diameter (ONSD) measured by ocular sonography and invasively measured intracranial pressure (ICP). The aim of this study was to evaluate changes in ONSD after lumbar epidural blood patch (EBP).

METHODS

Consecutive subjects receiving an EBP for PDPH were included. ONSD and pain measurements were performed before (T(0)), 10 min (M(10)), 2 h (H(2)), and 20 h (H(20)) after the EBP.

RESULTS

Ten subjects were included. ONSD [median (inter-quartile range)] increased with time after EBP, from 4.8 mm (4.5-5.1) at T(0) to 5.2 mm (4.9-5.7) at M(10) (P=0.005 vs T(0)), 5.5 mm (5.1-6.0) at H(2) (P=0.007 vs T(0)), and 5.8 mm (5.2-6.3) at H(20) (P=0.02 vs T(0)). EBP was clinically successful in nine of 10 subjects. In subjects in whom EBP was successful, ONSD significantly increased at M(10) and T(2) compared with T(0) (P=0.004 and 0.008, respectively) but did not reach statistical significance at H(20) (P=0.06). In the subject in whom EBP failed, a small increase in ONSD was observed over time.

CONCLUSIONS

In this preliminary report, EBP was followed by ONSD enlargement in subjects with successful EBP, but not in the subject with EBP failure. Since ONSD is a surrogate marker of ICP, this suggests that a sustained increase in ICP is associated with successful EBP.

Pseudotumor cerebri: brief review of clinical syndrome and imaging findings

PTC is a clinical entity of uncertain etiology characterized by intracranial hypertension. The syndrome classically manifests with headaches and visual changes in women with obesity. Traditionally, imaging ruled out secondary causes of elevated CSF pressure but now may reveal findings frequently seen in patients with PTC, including the following: flattening of the globe, an empty sella, an enlarged ONS, protrusion and enhancement of the optic nerve head, and increased tortuosity of the optic nerve. Novel imaging methods, including MR venography, have additionally identified sinovenous stenosis as a potential indicator of PTC.

MR imaging of the optic nerve sheath in patients with craniospinal hypotension

BACKGROUND AND PURPOSE

Craniospinal hyper- or hypotension leads to morphologic changes in certain intracranial structures. We tested the hypothesis that the amount of CSF in the ONS visible in MR imaging is reduced in patients with CSH.

MATERIALS AND METHODS

Nineteen patients with CSH were prospectively studied. Three readers assessed the width of the peri-optical CSF rim at 4 different anatomic positions by using coronal STIR sequences from a 3T MR imaging scanner. The height of the pituitary gland was also measured. Results were compared with normal values obtained with the same imaging technique. Qualitative signs of CSH also recorded were engorgement of venous sinuses, dural enhancement, subdural effusion, narrow ventricles, and sagging brain.

RESULTS

CSF signal intensity surrounding the optic nerves was diminished in at least 2 of the 4 positions used for measurements so that decreased diameters of the ONSs were observed in all patients (sensitivity, 100%; specificity, 97%). The height of the pituitary gland was above normal limits in 12 of 19 patients (sensitivity, 63%; specificity, 97%). Frequencies of qualitative signs of CSH varied from 32% to 81%.

CONCLUSIONS

The ISSON in patients with CSH is partially or fully collapsed due to reduced CSF content. In comparison with other anatomic markers, this sign showed the highest sensitivity for the diagnosis of patients with CSH in this study.

Theme: Neurology - Optic nerve sheath diameter measurement as a risk marker for significant intracranial hypertension

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.

Using MRI of the optic nerve sheath to detect elevated intracranial pressure

The current gold standard for the diagnosis of elevated intracranial pressure (ICP) remains invasive monitoring. Given that invasive monitoring is not always available or clinically feasible, there is growing interest in non-invasive methods of assessing ICP using diagnostic modalities such as ultrasound or magnetic resonance imaging (MRI). Increased ICP is transmitted through the cerebrospinal fluid surrounding the optic nerve, causing distention of the optic nerve sheath diameter (ONSD). In this issue of Critical Care, Geeraerts and colleagues describe a non-invasive method of diagnosing elevated ICP using MRI to measure the ONSD. They report a positive correlation between measurements of the ONSD on MRI and invasive ICP measurements. If the findings of this study can be replicated in larger populations, this technique may be a useful non-invasive screening test for elevated ICP in select populations.

Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure

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.