A Novel Triage Tool: Optic Nerve Sheath Diameter in Traumatic Brain Injury and its Correlation to Rotterdam Computed Tomography (CT) Scoring

Window into the mind: Advanced handheld spectroscopic eye-safe technology for point-of-care neurodiagnostic

Traumatic brain injury (TBI), a major cause of morbidity and mortality worldwide, is hard to diagnose at the point of care with patients often exhibiting no clinical symptoms. There is an urgent need for rapid point-of-care diagnostics to enable timely intervention. We have developed a technology for rapid acquisition of molecular fingerprints of TBI biochemistry to safely measure proxies for cerebral injury through the eye, providing a path toward noninvasive point-of-care neurodiagnostics using simultaneous Raman spectroscopy and fundus imaging of the neuroretina. Detection of endogenous neuromarkers in porcine eyes' posterior revealed enhancement of high-wave number bands, clearly distinguishing TBI and healthy cohorts, classified via artificial neural network algorithm for automated data interpretation. Clinically, translating into reduced specialist support, this markedly improves the speed of diagnosis. Designed as a hand-held cost-effective technology, it can allow clinicians to rapidly assess TBI at the point of care and identify long-term changes in brain biochemistry in acute or chronic neurodiseases.

Correlation Between Optic Nerve Sheath Diameter at Initial Head CT and the Rotterdam CT Score

Introduction Intracranial findings on imaging have long been used in assessing the severity of traumatic brain injury (TBI); the Rotterdam CT scoring (RCTS) is a more recent tool. Estimating the optic nerve sheath diameter (ONSD) at computed tomography (CT) can be another valuable predictor of the severity of the injury, especially as both ONSD and the RCTS are proven to be independent predictors of raised intracranial pressure (ICP). The study objective was to determine the correlation between ONSD at initial head CT and RCTS. Material and methods We observed 40 consecutive confirmed TBI cases at their initial head CT examinations in the emergency department for ONSD and the presence of other intracranial findings necessary to derive RCTS. The data were prospectively collected and analyzed, with statistical significance set at p ≤0.05 at 95% CI. Results The mean ONSD positively correlated with the Rotterdam CT score (r=0.368, p=0.019). A cut-off value of 6.83 mm was extrapolated from the receiver operator characteristic (ROC) curve as the mean binocular ONSD that best predicted severe RCTS (≥4) (sensitivity: 73.3%, specificity: 80%, positive predictive value: 68.7%, negative predictive value: 83.3%). The area under the curve (AUC) was 0.780 (p=0.003). Binary logistic regression analysis revealed an odd ratio (OR) of 11.000 (95% CI: 2.438-49.627; p=0.002). Conclusion TBI patients with high RCTS have wide mean binocular ONSD. Those with average binocular ONSD above the cut-off value are likelier to have severe TBI. With the documented good correlation, ONSD may become very useful in informing the clinical decision for sequential CT scans in TBI patients and, therefore, reducing the cumulative radiation burden from needless exposures. Furthermore, the non-invasive nature of its assessment will have more clinical relevance in resource-limited settings, where the skills and equipment for ICP monitoring are either not readily available or too expensive to be used routinely.

Acil servise kafa travması ile başvuran hastaların yönetiminde optik sinir kılıf çapı ölçümünün değerlendirilmesi

Amaç: Literatürde ultrasonografik olarak optik sinir kılıf çapı ölçümünde saptanan değerler, kafa içi basınç artışı ile ilişkilendirilmektedir. Kafa içi basıncı ölçümü yapılan hastalar kritik alan ya da yoğun bakım hastalarıdır. Hafif ya da orta şiddette kafa travmasında patolojiyi ya da operasyona gidişi öngörmede ultrasonografi ile optik sinir kılıf çapı ölçümünün etkisi değerlendirilmemiştir. Çalışmamızda kafa travması ile başvuran hastaların, ultrasonografi ile optik sinir kılıf çapı ölçüm değerlerini, kraniyal tomografi bulguları ve hastaların klinik sonlanımları ile karşılaştırmayı hedefledik. Gereç ve Yöntem: Prospektif kesitsel planlanan çalışmada acil servise başvuran kafa travmalı hastalar hafif, orta ve şiddetli beyin hasarı olarak değerlendirildi. Çalışmaya dahil edilen hastaların ultrasonografi ile optik sinir kılıf çapları ölçüldü. Bulgular hastaların sonlanımları ve kraniyal tomografi özellikleri ile karşılaştırıldı. Bulgular: Acil servise kafa travması ile başvuran 58 hastanın incelemesinde en sık hafif şiddette travmatik beyin hasarına rastlandı. Hastaların %51,7 (30)’sinde yatış ya da operasyon ihtiyacı vardı. Optik sinir kılıf çapı ölçümlerinin ortalaması sağda 4,96±1,02 mm (3,1-7,3) solda ise 4,92±1,02 mm (3,3-7,8) olarak bulunmuştur. Optik sinir kılıf çapı ölçüm değerlerinin 5 mm ve üzerinde saptanması hastaneye yatışı öngörmede istatistiksel olarak anlamlı olarak saptandı (p

Review: Emerging Eye-Based Diagnostic Technologies for Traumatic Brain Injury

The study of ocular manifestations of neurodegenerative disorders, Oculomics, is a growing field of investigation for early diagnostics, enabling structural and chemical biomarkers to be monitored overtime to predict prognosis. Traumatic brain injury (TBI) triggers a cascade of events harmful to the brain, which can lead to neurodegeneration. TBI, termed the "silent epidemic" is becoming a leading cause of death and disability worldwide. There is currently no effective diagnostic tool for TBI, and yet, early-intervention is known to considerably shorten hospital stays, improve outcomes, fasten neurological recovery and lower mortality rates, highlighting the unmet need for techniques capable of rapid and accurate point-of-care diagnostics, implemented in the earliest stages. This review focuses on the latest advances in the main neuropathophysiological responses and the achievements and shortfalls of TBI diagnostic methods. Validated and emerging TBI-indicative biomarkers are outlined and linked to ocular neuro-disorders. Methods detecting structural and chemical ocular responses to TBI are categorised along with prospective chemical and physical sensing techniques. Particular attention is drawn to the potential of Raman spectroscopy as a non-invasive sensing of neurological molecular signatures in the ocular projections of the brain, laying the platform for the first tangible path towards alternative point-of-care diagnostic technologies for TBI.

Evaluation of Sequential Head Computed Tomography in Traumatic Brain Injuries

Background: The grading of the severity of head trauma plays a vital role in acute patient management and planning a case-appropriate follow-up protocol. Few studies have been published regarding the Rotterdam scoring. In this study, we have established a correlation between the Rotterdam scores, need for sequential CTs, and the cumulative radiation dose. This correlation has helped develop a preliminary protocol that can be followed for patients hence bringing about better planned and efficient patient care.

Materials and methods: From August 2014 to December 2020, 88 cases of traumatic head injury on whom a minimum of one sequential CT was performed, with no surgical intervention, were included and studied. Sequential head CTs of each patient were evaluated by skilled radiologists with a minimum experience of five years, all of whom were blinded to the findings of the initial and previous head CT findings. The serial head CTs were evaluated for the Rotterdam CT score (RCTS). 

Results: Among the patients with extradural hemorrhage (EDH), only 28.6% (8) progressed over successive CTs and 75.5% (34) of patients with subdural hemorrhage (SDH) showed significant progression over sequential CTs. Maximum number of serial CTs were obtained for cases presenting with a score of 3 (34 cases) with about three of them requiring up to a total of three CTs. However, no significant change in findings was noted on serial CTs. On the contrary, significant disease progression was noted in patients with baseline scores of 4 (76.9%) and 5 (100%), with statistical significance obtained on further analysis (P = 0.001).

Conclusions: We are of the opinion that there is no additional role of sequential CT for the cases with Rotterdam score of 1 or 2 in the initial CT unless there is clinical evidence of deterioration. Rotterdam score 3 needs sequential CT after 24 hours and Rotterdam scores 4 and 5 need sequential CT after 12 hours if surgical intervention is delayed. The Rotterdam score may help predict any further need for a second CT, hence decreasing the unwanted radiation exposure.

Monitoring of optic nerve sheath diameter on computed tomography for noninvasive assessment of intracranial pressure: Case report: Optic nerve sheath and intracranial pressure

Introduction: It is important to measure intracranial pressure because traumatic brain injuries lead to intracranial hypertension and ischaemic brain lesions. The gold standard for measurement of intracranial pressure is invasive methods, but they can lead to complications and are not always available. Measurement of the optic nerve sheath diameter is a useful noninvasive way to estimate intracranial pressure and it can be done via ultrasonography, computed tomography and magnetic resonance imaging. Increased optic nerve sheath diameter on computed tomography can help to diagnose intracranial hypertension and to verify the need for urgent therapy and invasive measurements. Case report: We present 74 years old patient with traumatic brain injury and intracranial bleeding. Optic nerve sheath diameter was 6.81 mm on the left and 6.83 mm on the right side on the initial scan. In the coming days, existing haematomas were enlarged and there were newly formed haematomas, so there were changes in the optic nerve sheath diameter. After the haematoma evacuation, the sheath diameter was 6.56 mm on the left and 6.47 mm on the right side. At the time of the second neurologic deterioration, the sheath diameter was 7.43 mm on the left and 7.25 mm on the right side. On the 25th day, the diameter was 6.72 mm on the left and 6.41 mm on the right side. Conclusion: Measurement of the optic nerve sheath diameter is a significant additional diagnostic method for the assessment of intracranial hypertension and can help to decide on further treatment.

Efficacy of Noninvasive Technologies in Triaging Traumatic Brain Injury and Correlating With Intracranial Pressure: A Prospective Study

BACKGROUND

There is interest in methods of measuring noninvasive intracranial pressure (ICP), including pupillometry, ultrasonographic transcranial Doppler (TCD), and optic nerve sheath diameter (ONSD), for diagnosing traumatic brain injury (TBI) in limited resource environments. Whether these technologies have diagnostic agreement is unknown. We hypothesized that ONSD, pupillometry, and TCD could both distinguish severe TBI and correlate with ICP.

METHODS

A prospective study of 135 patients was conducted at a level 1 trauma center. Four test groups were established: nontrauma patients with ICP monitoring, trauma patients without TBI, trauma patients with mild TBI, and trauma patients with severe TBI with ICP monitoring. All patients underwent daily measurements of ONSD, pupillometry, and TCD with both CX50 Sonosite and the Spencer ST3 Yi Pencil probe.

RESULTS

ONSD differed significantly in patients with severe TBI compared with patients with mild and no TBI, but did not correlate with ICP. Pupillometric constriction velocity, dilation velocity, and percent change in pupil diameter were significantly different in patients with severe TBI, but also did not correlate with ICP. TCD did not differ among TBI severities, but middle cerebral artery peak systolic velocity, middle cerebral artery flow velocity, and carotid flow velocity correlated with ICP.

CONCLUSIONS

This is a novel study of four noninvasive tests to screen for severity of TBI and measure ICP. Our analysis indicates that no single device can do both. However, ONSD and pupillometry may be used as a supplementary screening tool for severe TBI, whereas TCD could be used to estimate and follow ICP in patients with severe TBI.

Relationship of Optic Nerve Sheath Diameter and Intracranial Hypertension in Patients with Traumatic Brain Injury

Background

to study the association between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in patients with moderate-to-severe brain injury.

Patients and Methods

A retrospective cohort study of traumatic brain injury (TBI) patients was conducted between 2010 and 2014. Data were analyzed and compared according to the ICP monitoring cutoff values. Outcomes included intracranial hypertension (ICH) and mortality.

Results

A total of 167 patients with a mean age of 33 ± 14 years, of them 96 had ICP monitored. ICP values correlated with ONSD measurement (r = 0.21, P = 0.04). Patients who developed ICH were more likely to have higher mean ONSD (P = 0.01) and subarachnoid hemorrhage (SAH) (P = 0.004). Receiver operating curve for ONSD showed a cutoff value of 5.6 mm to detect ICH with sensitivity 72.2% and specificity 50%. Age and ICP were independent predictors of inhospital mortality in multivariate model. Another model with same covariates showed ONSD and SAH to be independent predictors of ICH. Simple linear regression showed a significant association of ONSD with increased ICP (β = 0.21, 95% confidence interval 0.25-5.08, P = 0.03).

Conclusions

ONSD is a simple noninvasive measurement on initial CT in patients with TBI that could be a surrogate for ICP monitoring. However, further studies are warranted.

Comparative and retrospective evaluation of the predictive performance of optic nerve sheath thickness and optic nerve sheath diameter for traumatic brain injury using facial computed tomography

OBJECTIVE

To evaluate the predictive performance of optic nerve sheath thickness (ONST) on the outcomes of traumatic brain injury (TBI) and to compare the inter-observer agreement To evaluate the predictive performance of optic nerve sheath thickness (ONST) for traumatic brain injury (TBI) and to compare the predictive performance and inter-observer agreement between ONST and optic nerve sheath diameter (ONSD) on facial computed tomography (CT).

METHODS

We retrospectively enrolled patients with a history of facial trauma and who underwent both facial CT and brain CT. Two reviewers independently measured ONST and ONSD of each patient using facial CT images. Final brain CT with clinical outcome was used as the reference standard for TBI. Multivariate logistic regression analyses, receiver operating characteristic (ROC) curves, and intraclass correlation coefficients were used for statistical analyses.

RESULTS

Both ONST (P=0.002) and ONSD (P=0.001) on facial CT were significantly independent factors to distinguish between TBI and healthy brains; an increase in ONST and ONSD values corresponded with an increase in the risk of TBI by 8.9- and 7.6-fold, respectively. The predictive performances of the ONST (sensitivity, 96.2%; specificity, 94.3%; area under the ROC curve, 0.968) and ONSD (sensitivity, 92.6%; specificity, 90.2%; area under the ROC curve, 0.955) were excellent and exhibited similar sensitivity, specificity, and area under the curve (P=0.18-0.99). Interobserver and intraobserver intraclass correlation coefficients for ONST were significantly higher than those for ONSD (all P<0.001).

CONCLUSION

ONST on facial CT is a feasible predictor of TBI and demonstrates similar performance and superior observer agreement than ONSD. We recommend using ONST measurements to assess the need for additional brain CT scans in TBI-suspected cases.

Optic nerve sheath diameter ultrasonography for elevated intracranial pressure detection

Ultrasonographically measured optic nerve sheath diameter measurement has become a common noninvasive approach for detecting elevated intracranial pressure. We present a case of aneurysmal subarachnoid hemorrhage with elevated intracranial pressure. Postoperative arachnoiditis developed, and lumbar puncture revealed low intracranial pressure. However, ultrasonography revealed a dilated optic nerve sheath, denoting elevated intracranial pressure. This was confirmed by computed tomography showing ventricular dilation. Ophthalmoscopy revealed papilledema and hemorrhage. This case study demonstrated that noninvasive bedside ultrasonographic optic nerve sheath diameter measurement can detect elevated intracranial pressure more accurately than lumbar puncture, especially in cases with intracranial infection.

The Use of Rotterdam CT Score for Prediction of Outcomes in Pediatric Traumatic Brain Injury Patients Admitted to Emergency Service

INTRODUCTION

Rotterdam CT score for prediction of outcome in traumatic brain injury is widely used for patient evaluation. The data on the assessment of pediatric traumatic brain injury patients with the Rotterdam scale in our country are still limited. In this study, we aimed to evaluate the use of the Rotterdam scale on pediatric trauma patients in our country and assess its relationship with lesion type, location and severity, trauma type, and need for surgery.

METHODS

A total of 229 pediatric patients admitted to the emergency service due to head trauma were included in our study. Patients were evaluated in terms of age, gender, Glasgow Coma Scale (GCS), initial and follow-up Rotterdam scale scores, length of stay, presence of other traumas, seizures, antiepileptic drug use, need for surgical necessity, and final outcome.

RESULTS

A total of 229 patients were included in the study, and the mean age of the patients was 95.8 months. Of the patients, 87 (38%) were girls and 142 (62%) were boys. Regarding GCS at the time of admission, 59% (n = 135) of the patients had mild (GCS = 13-15), 30.6% (n = 70) had moderate (GCS = 9-12), and 10.5% (n = 24) had severe (GCS < 9) head trauma. The mean Rotterdam scale score was calculated as 1.51 (ranging from 1 to 3) for mild, 2.22 (ranging from 1 to 4) for moderate, and 4.33 (ranging from 2 to 6) for severe head trauma patients. Rotterdam scale score increases significantly as the degree of head injury increases (p < 0.001).

DISCUSSION

With the adequate use of GCS and cerebral computed tomography imaging, pediatric patients with a higher risk of mortality and need for surgery can be predicted. We recommend the follow-up of pediatric traumatic brain injury patients with repeated CT scans to observe alterations in Rotterdam CT scores, which may be predictive for the need for surgery and intensive care.

A noninvasive method for the estimation of increased intracranial pressure in patients with severe traumatic brain injury using optic nerve sheath diameter measured on computed tomography head

Background:

Measurement of optic nerve sheath diameter (ONSD) using ocular ultrasonography has shown a promise in predicting increased intracranial pressure (ICP). However, this method is dependent on operator technique and equipment availability. We propose an alternative method of measuring ONSD and Marshall score grading by utilizing initial computed tomography (CT) head obtained on admission. We believe that such a technique could help predict patients requiring an invasive ICP monitor on admission.

Methods:

Patients were retrospectively selected from the neurosurgery database of a level II trauma center. Control patients originated from a database of nontraumatic brain injury (TBI) patients with a negative CT head and no intracranial pathology. Study subjects included patients aged 18–90 years, who sustained a severe TBI requiring placement of an ICP monitor on admission. All patients had a non-contrast CT head before the placement of an ICP monitor. Patients receiving any intervention for decreasing suspected elevated ICPs and those with any documented orbital fractures before ICP monitor placement were excluded from the study. All measurements were performed by at least of two independent assessors.

Results:

A total of 242 patients were reviewed, of which 204 (100 control and 104 intervention) met inclusion criteria for this study. T he average age in the control group was 49.1 ± 22.9 years old while the average age of the intervention group was 36.9 ± 15.1 years (P < 0.0001). The average Glasgow Coma Scale was 7 in the intervention group. The average ONSD of the control group was 5.73 ± 0.58 mm compared to 6.76 ± 0.83 mm in the intervention group (P < 0.0001). Linear regression analysis demonstrated a statistically significant correlation between ONSD and opening ICP (r = 0.40, P < 0.001) and peak ICP (r = 0.31, P < 0.0001). An ONSD ≥6.0 mm + Marshall score ≥3 on initial CT head demonstrated a 92.5% sensitivity, 92.6% specificity, and 96.1% positive predictive value for developing an ICP ≥20 mmHg during hospitalization.

Conclusion:

Utilizing ONSD in combination with Marshall score grading on initial CT head is a strong predictor of elevated ICP. These criteria can be used in future studies to develop more objective criteria to guide ICP monitor placement.

Is initial optic nerve sheath diameter prognostic of specific head injury in emergency departments?

BACKGROUND

Emergency departments (EDs) are typically the first medical contact for patients with traumatic brain injury (TBI) and early diagnosis and treatment of intracranial pressure (ICP) in patients with neurotrauma primarily falls under the liability of emergency doctors. Monitoring ICP with optic nerve sheath diameter (ONSD) via tools has gained popularity among emergency service doctors. In this study, we aimed to evaluate the predictive value of ONSD for specific head injury on initial cranial tomography.

METHODS

CT scans of 176 patients with a known intracranial pathology were retrospectively analyzed and compared with normal control CTs of 182 patients presented to ED at the same time interval. The attending radiologist analyzed all initial brain CT scans and randomly sampled control CTs were similarly assessed by the second senior radiologist whom were blind to the patients' medical histories and circumstances of TBI at the time of measurement. ONSD was measured at a distance of 3 mm behind the eyeball, immediately below the sclera.

RESULTS

Right ONSD value was significantly higher in patients with herniation and SAH (p = 0,024 and 0,028, respectively). Left ONSD values was at the level of statistical significance and mean ONSD values was significantly higher in patients with SAH (p = 0.05 and 0.026, respectively). Right-left-mean ONSD values were statistically higher in study group with bilateral lesions on brain CT (p < 0,001). ONSD measurements and patient age were higher in patients who died (p < 0,001).

CONCLUSIONS

ONSD measurement on initial brain CT is lesion dependent and indicates mortality.

Optic nerve sheath diameter on facial CT: a tool to predict traumatic brain injury

PURPOSE

To evaluate and compare the optic nerve sheath diameters (ONSDs) of facial trauma patients as observed on facial CT and brain CT, and to evaluate the predictive performance of ONSD as seen on facial CT for traumatic brain injury (TBI).

METHODS

We retrospectively enrolled 262 patients with facial trauma who underwent both facial CT and brain CT. Two reviewers independently measured ONSD at 3 mm (ONSD3) and 10 mm behind the globe (ONSD10) for each patient on both CT scans. Final CT reports with clinical progress notes were used as the reference standard. Statistically, multivariate logistic regression analysis, receiver operating characteristic (ROC) curves, and intraclass correlation coefficients (ICCs) were used.

RESULTS

Eighty-seven (33.2%) patients were diagnosed with facial fracture, and 21 (8.0%) were diagnosed with intracranial haemorrhage. Neither reviewer observed significant differences (p = 0.15-0.61) between facial CT and brain CT when comparing ONSD3 and ONSD10. ONSD3 on facial CT was a significantly independent factor for distinguishing TBI from negative brain CT scan (p = 0.001); as ONSD3 increased, the risk of TBI increased 8.1-fold. ONSD3 ≥ 4.13 mm exhibited the highest area under the ROC curve (AUC) for predicting TBI (AUC, 0.968; sensitivity, 90.5%; specificity, 98.8%). There were good or excellent interobserver agreements for all measurements (ICC, 0.750-0.875).

CONCLUSION

ONSD3 as determined by facial CT is a feasible predictive marker of TBI in facial trauma patients. It can assist emergency physicians in deciding whether immediate further brain imaging is warranted.