Identification of optic disc elevation and the crescent sign using point-of-care ocular ultrasound in children

Diagnostic dilemma of papilledema and pseudopapilledema

BACKGROUND

Papilledema is the optic disc swelling caused by increased intracranial pressure (ICP) that can damage the optic nerve and cause subsequent vision loss. Pseudopapilledema refers to optic disc elevation without peripapillary fluid that can arise from several optic disc disorders, with optic disc drusen (ODD) being the most frequent cause. Occasionally, pseudopapilledema patients are mistakenly diagnosed as papilledema, leading to the possibility of unneeded procedures. We aim to thoroughly examine the most current evidence on papilledema and pseudopapilledema causes and several methods for distinguishing between both conditions.

METHODS

An extensive literature search was conducted on electronic databases including PubMed and google scholar using keywords that were relevant to the assessed pathologies. Data were collected and then summarized in comprehensive form.

RESULTS

Various techniques are employed to distinguish between papilledema and pseudopapilledema. These techniques include Fundus fluorescein angiography, optical coherence tomography, ultrasonography, and magnetic resonance imaging. Lumbar puncture and other invasive procedures may be needed if results are suspicious.

CONCLUSION

Papilledema is a sight-threatening condition that may lead to visual affection. Many disc conditions may mimic papilledema. Accordingly, differentiation between papilledema and pseudopailledema is crucial and can be conducted through many modalities.

Transorbital point-of-care ultrasound versus fundoscopic papilledema to support treatment indication for potentially elevated intracranial pressure in children

PURPOSE

To compare transorbital point-of-care ultrasound techniques -optic nerve sheath diameter (US-ONSD) and optic disc elevation (US-ODE)- with fundoscopic papilledema to detect potentially raised intracranial pressure (ICP) with treatment indication in children.

METHODS

In a prospective study, 72 symptomatic children were included, 50 with later proven disease associated with raised ICP (e.g. pseudotumour cerebri, brain tumour, hydrocephalus) and 22 with pathology excluded. Bilateral US-ONSD and US-ODE were quantified by US using a 12-MHz-linear-array transducer. This was compared to fundoscopic optic disc findings (existence of papilledema) and, in 28 cases, invasively measured ICP values.

RESULTS

The sensitivity and specificity of a cut-off value of US-ONSD (5.73 mm) to detect treatment indication for diseases associated with increased ICP was 92% and 86.4%, respectively, compared to US-ODE (0.43 mm) with sensitivity: 72%, specificity: 77.3%. Fundoscopic papilledema had a sensitivity of 46% and a specificity of 100% in this context. Repeatability and observer-reliability of US-ODE examination was eminent (Cronbach's α = 0.978-0.989). Papilledema was detected fundoscopically only when US-ODE was > 0.67 mm; a US-ODE > 0.43 mm had a positive predictive value of 90% for potentially increased ICP.

CONCLUSION

In our cohort, transorbital point-of-care US-ONSD and US-ODE detected potentially elevated ICP requiring treatment in children more reliably than fundoscopy. US-ONSD and US-ODE indicated the decrease in ICP after treatment earlier and more reliably than fundoscopy. The established cut-off values for US-ONSD and US-ODE and a newly developed US-based grading of ODE can be used as an ideal first-line screening tool to detect or exclude conditions with potentially elevated ICP in children.

Influence of sex and disease etiology on the development of papilledema and optic nerve sheath extension in the setting of intracranial pressure elevation in children

Introduction

Dilatation of the optic nerve sheath diameter and swelling of the optic disc are known phenomena associated with intracranial pressure elevation.

Research question

Do sex and disease etiology have an impact on the development of optic disc elevation and optic nerve sheath extension in children in the setting of ICP elevation? Fundoscopic papilledema and point-of-care-ultrasound techniques-optic nerve sheath diameter (US-ONSD) and optic disc elevation (US-ODE) - were compared in this regard.

Material and methods

72 children were included in this prospective study; 50 with proven pathology (e.g. pseudotumor cerebri, tumor), 22 with pathology excluded. Bilateral US-ONSD and US-ODE were quantified by US using a 12-MHz-linear-array-transducer. This was compared with fundoscopic optic disc findings and in 28 patients with invasive ICP values, stratified for sex and etiology.

Results

In patients with proven disease, significant more girls (69%) had fundoscopic papilledema compared with boys (37%, p < 0.05). Girls had also larger US-ODE values (0.86 ± 0.36 mm vs. 0.65 ± 0.40 mm in boys). 80% of tumor patients had initial papilledema (100% girls, 79% boys), compared with 50% in pseudotumor cerebri (PTC) (83% girls, 30% boys). US-ONSD had no sex- and no etiology-specificity.

Discussion and conclusion

Presence of papilledema appears to be influenced by sex and etiology, whereas US-ONSD is not. Girls seem more likely to develop papilledema under similar conditions. Male sex and PTC appear as risk factors for being undetected by fundoscopic findings. US-ONSD and US-ODE seem useful tools to identify pathologies with potentially increased ICP requiring treatment in children regardless of sex and etiology.

Ultrasound detected increase in optic disk height to identify elevated intracranial pressure: a systematic review

BACKGROUND

Elevated intracranial pressure (eICP) is a serious medical emergency that requires prompt identification and monitoring. The current gold standards of eICP detection require patient transportation, radiation, and can be invasive. Ocular ultrasound has emerged as a rapid, non-invasive, bedside tool to measure correlates of eICP. This systematic review seeks to explore the utility of ultrasound detected optic disc elevation (ODE) as an ultrasonographic finding of eICP and to study its sensitivity and specificity as a marker of eICP.

METHODS

This systematic review followed the preferred reporting items for systematic reviews and meta-analyses guidelines. We systematically searched PubMed, EMBASE, and Cochrane Central for English articles published before April 2023; yielding 1,919 total citations. After eliminating duplicates, and screening the records, we identified 29 articles that addressed ultrasonographically detected ODE.

RESULTS

The 29 articles included a total of 1249 adult and pediatric participants. In patients with papilledema, the mean ODE ranged between 0.6 mm and 1.2 mm. Proposed cutoff values for ODE ranged between 0.3 mm and 1 mm. The majority of studies reported a sensitivity between 70 and 90%, and specificity ranged from 69 to 100%, with a majority of studies reporting a specificity of 100%.

CONCLUSIONS

ODE and ultrasonographic characteristics of the optic disc may aid in differentiating papilledema from other conditions. Further research on ODE elevation and its correlation with other ultrasonographic signs is warranted as a means to increase the diagnostic accuracy of ultrasound in the setting of eICP.

Diagnostic Accuracy of Ocular Ultrasonography in Identifying Raised Intracranial Pressure among Pediatric Population

INTRODUCTION

Role of CT scan, MRI, ophthalmoscopy, direct monitoring by a transducer probe in identifying raised intracranial pressure (ICP) in emergency department is limited. There are few studies correlating elevated optic nerve sheath diameter (ONSD) measured by point of care ultrasound (POCUS) with raised ICP in pediatrics emergencies. We studied the diagnostic accuracy of ONSD, crescent sign, and optic disc elevation in identifying increased ICP in pediatrics.

METHODS

Prospective observational study was done between April 2018 and August 2019 after ethics approval. Out of 125 subjects, 40 patients without clinical features of raised ICP were recruited as external controls and 85 with clinical features of raised ICP as study subjects. Their demographic profile, clinical examination, and ocular ultrasound findings were noted. This was followed by CT scan. Out of 85 patients, 43 had raised ICP (cases) and 42 had normal ICP (disease controls). Diagnostic accuracy of ONSD in identifying raised ICP was evaluated using STATA.

RESULTS

The mean ONSD in case group was 5.5 ± 0.6 mm, 4.9 ± 0.5 mm in disease control group and external control group was 4.8 ± 0.3 mm. Cut-off of ONSD for raised ICP at ≥4.5 mm had a sensitivity and specificity of 97.67% and 10.98%, while ≥5.0 mm showed a sensitivity and specificity of 86.05% and 71.95%. Crescent sign and optic disc elevation had good correlation with increased ICP.

CONCLUSION

ONSD ≥5 mm by POCUS identified raised ICP in pediatric population. Crescent sign and optic disc elevation may function as additional POCUS signs in identifying raised ICP.

Identification of Papilledema in Pediatric Patients With Meningitis Using Ocular Point-of-Care Ultrasound

ABSTRACT

Ocular point-of-care ultrasound is used by physicians for an array of diagnoses. In this case series, we describe how pediatric emergency medicine physicians utilized ocular point-of-care ultrasound in the management of patients with papilledema secondary to meningitis or its treatment.

Ultrasonic optic disc height combined with the optic nerve sheath diameter as a promising non-invasive marker of elevated intracranial pressure

Background/aim: Patients with elevated intracranial pressure (ICP) tend to have optic disc edema and a thicker optic nerve sheath diameter (ONSD). However, the cut-off value of the optic disc height (ODH) for evaluating elevated ICP is not clear. This study was conducted to evaluate ultrasonic ODH and to investigate the reliability of ODH and ONSD for elevated ICP.

Methods: Patients suspected of having increased ICP and who underwent a lumbar puncture were recruited. ODH and ONSD were measured before lumbar puncture. Patients were divided according to elevated and normal ICP. We analyzed the correlations between ODH, ONSD, and ICP. ODH and ONSD cut-off points for the identification of elevated ICP were determined and compared.

Results: There were a total of 107 patients recruited for this study, 55 patients with elevated ICP and 52 with normal ICP. Both ODH and ONSD in the elevated ICP group were higher than in the normal group [ODH: median 0.81 (range 0.60–1.06) mm vs. 0.40 [0–0.60] mm, p &lt; 0.001; ONSD: 5.01 ± 0.37 mm vs. 4.20 ± 0.38 mm, p &lt; 0.001]. ICP was positively correlated with ODH (r = 0.613; p &lt; 0.001) and ONSD (r = 0.792; p &lt; 0.001). The cut-off values of ODH and ONSD for evaluating elevated ICP were 0.63 mm and 4.68 mm, respectively, with 73% and 84% sensitivity and 83% and 94% specificity, respectively. ODH combined with ONSD showed the highest value under the receiver operating characteristic curve of 0.965 with a sensitivity of 93% and a specificity of 92%.

Conclusion: Ultrasonic ODH combined with ONSD may help monitor elevated ICP non-invasively.

Diagnostic Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound has become an essential part of pediatric emergency medicine training and practice. It can have significant clinical benefits, including improving diagnostic accuracy and decreasing length of stay, and does not require radiation exposure for patients. In this review, we summarize the current diagnostic point-of-care ultrasound applications in pediatric emergency medicine, their evidence, and techniques.

Utility of Point-of-Care Ultrasound in the Diagnosis of Idiopathic Intracranial Hypertension in the Emergency Department

BACKGROUND

Emergency physicians are frequently required to identify and triage patients with increased intracranial pressure (ICP). Idiopathic intracranial hypertension (IIH) is a possible cause that must be considered. Its prognosis depends on prompt recognition and treatment, and progression of the disease can lead to permanent vision loss and considerable morbidity. Point-of-care ultrasound can rapidly identify elevated ICP. Measurements of the optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) can act as surrogates for ICP.

CASE SERIES

We describe five cases in which ultrasound was used to identify increased ICP and aid clinical decision-making. In several of the cases, ultrasound was used to confirm a suspicion for IIH and initiate therapy while awaiting the results of a more time-consuming and technically challenging test, such as lumbar puncture or optical coherence tomography. One of the patients was pregnant, and sonographic evidence of elevated ICP helped avoid exposing the patient to unnecessary radiation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound is a quick and versatile tool for screening patients with neurologic symptoms, and when integrated into the proper clinical context, can reduce the use of more invasive tests. It can be particularly useful in patients with pathology that may not show abnormalities on computed tomography scan or in whom lumbar puncture is technically difficult, making patients at risk for IIH well-suited to examination by ultrasound. We use a cutoff of 5 mm for ONSD and 0.6 mm for ODE, though there are no universally agreed on cutoff values.

Point-of-care ultrasound of optic nerve sheath diameter to detect intracranial pressure in neurocritically ill children - A narrative review

The rapid diagnosis of increased intracranial pressure is urgently needed for therapeutic reasons in neurocritically ill children, however this can rarely be achieved without invasive procedures. Point-of-care ultrasound of the optic nerve sheath diameter has been proposed as a non-invasive and reliable means to detect increased intracranial pressure in adults. Accordingly, clinicians may be able to use this technique to initiate early treatment and monitor the effectiveness of treatment in conjunction with other clinical examination and diagnostic modalities. Two meta-analyses and a systematic review have been published on this topic in adults. However, data on the correlation between optic nerve sheath diameter and intracranial pressure in neurocritically ill children are scarce. The aim of this review was to briefly describe what is being measured with point-of-care ultrasound of the optic nerve sheath diameter, summarize the most recent findings from adult literature, and provide an update of current work in children.

Determination of cerebral edema with serial measurement of optic nerve sheath diameter during treatment in children with diabetic ketoacidosis: a longitudinal study

Background Cerebral edema is a fatal complication that can occur in children with diabetic ketoacidosis (DKA). Its clinical signs are generally not explicit, and subclinical cerebral edema can occur. This study is one of the few longitudinal studies conducted to identify cerebral edema in patients with DKA by measuring the optic nerve sheath diameter (ONSD). The aim of this study was to investigate cerebral edema in children with DKA with serial measurement of ONSD, which is an early and reliable indicator of cerebral edema, and to monitor changes in ONSD during therapy. Methods The study was conducted by measuring ONSD ultrasonographically at baseline and during the course of therapy in patients with DKA. All participants were diagnosed and received therapy at our unit between May 2016 and June 2017. The study was registered with the Clinical Trials database, with a study number of NCT02937441. Measurements were obtained while the patients were in the supine position with their eyes closed, and axial transbulbar images of both eyes were obtained with a 6-15-MHz linear probe. Results The ONSD values of children with DKA changed during the treatment, reaching the highest values at 12-16 h of therapy, and the greatest ONSD was observed in children who had moderate and severe DKA. Conclusions During treatment of children with DKA, it is possible to predict cerebral edema by measuring ONSD, and this may contribute to clinical management, especially fluid treatment.

Ocular Ultrasonography: A Useful Instrument in Patients with Trauma Brain Injury in Emergency Service

The measurement of the optic nerve sheath by ocular ultrasonography might be an indirect method to assess the quickly increase of the intracranial pressure in patients with moderate trauma brain injury, taking into account that an important proportion of these could develop the increase of the intracranial pressure in a hospital-acquired way. Therefore noninvasive, reliable, and convenient techniques are needed making the ocular ultrasonography a useful tool, due to the invasive monitoring elements' problems and the poor access to measure the intracranial pressure in emergency services. In spite of the limitations and few studies that exist to consider it as a possible early detection, this technique could work as a noninvasive one in the case that could not be possible to do invasive monitoring or when it is not recommended.

Identification of Optic Nerve Swelling Using Point-of-Care Ocular Ultrasound in Children

OBJECTIVE

The aim of this study was to determine the feasibility and accuracy of point-of-care (POC) ocular ultrasound (US) when performed by a pediatric emergency medicine (PEM) physician to detect optic nerve abnormalities concerning for swelling, as compared with the fundus examination performed by an ophthalmologist.

METHODS

This was a single-center, prospective cohort pilot study of children aged 12 months to 18 years who required optic disc evaluation by an ophthalmologist. Eligible subjects were enrolled from the emergency department, inpatient wards, and neuro-ophthalmology outpatient clinic of an urban, tertiary care children's hospital. Point-of-care ocular US, specifically assessing optic nerve sheath diameter and optic disc elevation, was performed. Findings on US were compared with findings identified by an ophthalmologist on dilated fundus examination.

RESULTS

Seventy-six subjects were enrolled; 20 (26%) of 76 had findings concerning for optic nerve swelling diagnosed by an ophthalmologist on fundus examination. Using a sonographic definition for optic nerve swelling of optic nerve sheath diameter greater than 4.5 mm or the presence of optic disc elevation, the sensitivity and specificity were 90% and 55%, respectively. The success rate of POC ocular US was 100%, and the mean time to completion was 8 minutes. For emergency department subjects in whom direct fundus examination was attempted, the PEM physician could visualize the optic disc and assess for swelling in only 40% (14/35) of examinations.

CONCLUSIONS

The results of our study suggest that POC ocular US performed by PEM physicians was feasible and determined to be sensitive but nonspecific in the detection of optic nerve swelling. Additional larger studies may determine generalizability to other nonophthalmologist physicians performing POC ocular US.