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Koshy P, Gadkari C. Measurement of Optic Nerve Sheath Diameter by Bedside Ultrasound in Patients With Traumatic Brain Injury Presenting to Emergency Department: A Review. Cureus 2024; 16:e61768. [PMID: 38975557 PMCID: PMC11227432 DOI: 10.7759/cureus.61768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 06/05/2024] [Indexed: 07/09/2024] Open
Abstract
The aim of this review article is to outline the effectiveness of using bedside ultrasound to measure the optic nerve sheath diameter (ONSD) in order to identify variations in intracranial pressure (ICP) and subsequently avoid the complication of secondary brain injury in patients with traumatic brain injury (TBI), who are admitted to an emergency department (ED). Reputable publications and numerous studies demonstrate the problem's exponential rampancy and pervasiveness. In a TBI patient, the emergence of secondary brain damage has been recognized as a serious emergency. It is believed that secondary brain damage is caused by an abnormally high ICP. High levels of ICP can be measured using both invasive and non-invasive approaches. ONSD measurement via bedside ultrasound has been identified as a quick, useful technique to be used in the ED to avoid potential morbidity and mortality owing to secondary brain injury.
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Affiliation(s)
- Preethy Koshy
- Emergency Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Charuta Gadkari
- Emergency Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Kshirsagar SJ, Pande AH, Naik SV, Yadav A, Sakhala RM, Salve SM, Nuhaimah A, Desai P. Bedside ultrasonographic evaluation of optic nerve sheath diameter for monitoring of intracranial pressure in traumatic brain injury patients: a cross sectional study in level II trauma care center in India. Acute Crit Care 2024; 39:155-161. [PMID: 38476068 PMCID: PMC11002624 DOI: 10.4266/acc.2023.01172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Optic nerve sheath diameter (ONSD) is an emerging non-invasive, easily accessible, and possibly useful measurement for evaluating changes in intracranial pressure (ICP). The utilization of bedside ultrasonography (USG) to measure ONSD has garnered increased attention due to its portability, real-time capability, and lack of ionizing radiation. The primary aim of the study was to assess whether bedside USG-guided ONSD measurement can reliably predict increased ICP in traumatic brain injury (TBI) patients. METHODS A total of 95 patients admitted to the trauma intensive care unit was included in this cross sectional study. Patient brain computed tomography (CT) scans and Glasgow Coma Scale (GCS) scores were assessed at the time of admission. Bedside USG-guided binocular ONSD was measured and the mean ONSD was noted. Microsoft Excel was used for statistical analysis. RESULTS Patients with low GCS had higher mean ONSD values (6.4±1.0 mm). A highly significant association was found among the GCS, CT results, and ONSD measurements (P<0.001). Compared to CT scans, the bedside USG ONSD had 86.42% sensitivity and 64.29% specificity for detecting elevated ICP. The positive predictive value of ONSD to identify elevated ICP was 93.33%, and its negative predictive value was 45.00%. ONSD measurement accuracy was 83.16%. CONCLUSIONS Increased ICP can be accurately predicted by bedside USG measurement of ONSD and can be a valuable adjunctive tool in the management of TBI patients.
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Affiliation(s)
- Sujit J. Kshirsagar
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Anandkumar H. Pande
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Sanyogita V. Naik
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Alok Yadav
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Ruchira M. Sakhala
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Sangharsh M. Salve
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Aysath Nuhaimah
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
| | - Priyanka Desai
- Department of Anesthesiology and Critical Care, B. J. Government Medical College and Sassoon General Hospital, Pune, India
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Gedeno K, Neme D, Jemal B, Aweke Z, Achule A, Geremu K, Bekele Uddo T. Evidence-based management of adult traumatic brain injury with raised intracranial pressure in intensive critical care unit at resource-limited settings: a literature review. Ann Med Surg (Lond) 2023; 85:5983-6000. [PMID: 38098558 PMCID: PMC10718354 DOI: 10.1097/ms9.0000000000001291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 12/17/2023] Open
Abstract
Background In underdeveloped countries, there is a greater incidence of mortality and morbidity arising from trauma, with traumatic brain injury (TBI) accounting for 50% of all trauma-related deaths. The occurrence of elevated intracranial pressure (ICP), which is a common pathophysiological phenomenon in cases of TBI, acts as a contributing factor to unfavorable outcomes. The aim of this systematic review is to analyze the existing literature regarding the management of adult TBI with raised ICP in an intensive critical care unit, despite limited resources. Methods This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis protocol. Search engines such as PubMed, the Cochrane database, and Google Scholar were utilized to locate high-level evidence that would facilitate the formation of sound conclusions. Result A total of 11 715 articles were identified and individually assessed to determine their eligibility for inclusion or exclusion based on predetermined criteria and outcome variables. The methodological quality of each study was evaluated using recommended criteria. Ultimately, the review consisted of 51 articles. Conclusion Physical examination results and noninvasive assessments of the optic nerve sheath diameter (ONSD) via sonography are positively associated with elevated ICP, and are employed as diagnostic and monitoring tools for elevated ICP in resource-limited settings. Management of elevated ICP necessitates an algorithmic approach that utilizes prophylactic measures and acute intervention treatments to mitigate the risk of secondary brain injury.
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Affiliation(s)
- Kanbiro Gedeno
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | | | | | - Zemedu Aweke
- Department of Anesthesia
- School of Clinical Science, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Astemamagn Achule
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | - Kuchulo Geremu
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | - Tesfanew Bekele Uddo
- Department of Surgery, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia
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Berhanu D, Ferreira JC, Abegão Pinto L, Aguiar de Sousa D, Lucas Neto L, Tavares Ferreira J. The role of optic nerve sheath ultrasonography in increased intracranial pressure: A systematic review and meta analysis. J Neurol Sci 2023; 454:120853. [PMID: 37925899 DOI: 10.1016/j.jns.2023.120853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To review the optimal diagnostic cut-off of ultrasonographic optic nerve sheath diameter (ONSD) in the diagnosis of increased intracranial pressure (IICP). METHODS A systematic search was conducted of available studies assessing the use of ONSD ultrasonography in patients with suspected IICP. Meta-analysis of diagnostic accuracy of ultrasonographic ONSD was performed using a bivariate model of random effects to summarize pooled sensitivity and specificity. A summary receiver operating characteristics (SROC) curve was plotted. Accuracy measures associated with ONSD cut-off and predefined covariates were investigated with meta-regression. RESULTS We included 38 studies, comprising a total of 2824 patients. A total of 21 studies used invasive techniques as a reference standard estimation of IICP and meta-analysis revealed a pooled sensitivity of 0.90 (95% CI 0.85-0.93) and specificity of 0.87 (95% CI 0.80-0.91). Optimal ONSD cut-off values ranged between 4.1 mm and 7.2 mm. Meta-regression analysis showed that ONSD cut-off values of 5.6 to 6.3 mm were associated with higher pooled specificity compared to cut-off values of 4.9 to 5.5 mm (0.93, 95% CI 0.85-0.97 vs. 0.78, 95% CI 0.65-0.87; p = 0.036). CONCLUSIONS Ultrasonography of ONSD shows a high diagnostic accuracy for IICP, with high pooled sensitivity and specificity. Additionally, larger cut-off values seem to significantly increase specificity without compromising sensitivity, which support their use as optimal ONSD cut-off. The overall high sensitivity of ultrasonographic ONSD suggests its usefulness as a screening tool for IIC, which may provide an estimate of when invasive methods are warranted. CLINICAL RELEVANCE ONSD ultrasonography is a fast and cost-effective method with a high diagnostic accuracy to detect IICP. The optimum ONSD cut-off hasn't been established before, but we suggest the 5.6 to 6.3 mm range as the best for the diagnosis of IICP.
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Affiliation(s)
- David Berhanu
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal; Serviço de Imagiologia Neurológica, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.
| | | | - Luís Abegão Pinto
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal; Serviço de Oftalmologia, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Diana Aguiar de Sousa
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal; Unidade Cerebrovascular, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Lia Lucas Neto
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal; Serviço de Imagiologia Neurológica, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Joana Tavares Ferreira
- Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal; Serviço de Oftalmologia, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
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Stojek L, Bieler D, Neubert A, Ahnert T, Imach S. The potential of point-of-care diagnostics to optimise prehospital trauma triage: a systematic review of literature. Eur J Trauma Emerg Surg 2023; 49:1727-1739. [PMID: 36703080 PMCID: PMC10449679 DOI: 10.1007/s00068-023-02226-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 01/07/2023] [Indexed: 01/27/2023]
Abstract
PURPOSE In the prehospital care of potentially seriously injured patients resource allocation adapted to injury severity (triage) is a challenging. Insufficiently specified triage algorithms lead to the unnecessary activation of a trauma team (over-triage), resulting in ineffective consumption of economic and human resources. A prehospital trauma triage algorithm must reliably identify a patient bleeding or suffering from significant brain injuries. By supplementing the prehospital triage algorithm with in-hospital established point-of-care (POC) tools the sensitivity of the prehospital triage is potentially increased. Possible POC tools are lactate measurement and sonography of the thorax, the abdomen and the vena cava, the sonographic intracranial pressure measurement and the capnometry in the spontaneously breathing patient. The aim of this review was to assess the potential and to determine diagnostic cut-off values of selected instrument-based POC tools and the integration of these findings into a modified ABCDE based triage algorithm. METHODS A systemic search on MEDLINE via PubMed, LIVIVO and Embase was performed for patients in an acute setting on the topic of preclinical use of the selected POC tools to identify critical cranial and peripheral bleeding and the recognition of cerebral trauma sequelae. For the determination of the final cut-off values the selected papers were assessed with the Newcastle-Ottawa scale for determining the risk of bias and according to various quality criteria to subsequently be classified as suitable or unsuitable. PROSPERO Registration: CRD 42022339193. RESULTS 267 papers were identified as potentially relevant and processed in full text form. 61 papers were selected for the final evaluation, of which 13 papers were decisive for determining the cut-off values. Findings illustrate that a preclinical use of point-of-care diagnostic is possible. These adjuncts can provide additional information about the expected long-term clinical course of patients. Clinical outcomes like mortality, need of emergency surgery, intensive care unit stay etc. were taken into account and a hypothetic cut-off value for trauma team activation could be determined for each adjunct. The cut-off values are as follows: end-expiratory CO2: < 30 mm/hg; sonography thorax + abdomen: abnormality detected; lactate measurement: > 2 mmol/L; optic nerve diameter in sonography: > 4.7 mm. DISCUSSION A preliminary version of a modified triage algorithm with hypothetic cut-off values for a trauma team activation was created. However, further studies should be conducted to optimize the final cut-off values in the future. Furthermore, studies need to evaluate the practical application of the modified algorithm in terms of feasibility (e.g. duration of application, technique, etc.) and the effects of the new algorithm on over-triage. Limiting factors are the restriction with the search and the heterogeneity between the studies (e.g. varying measurement devices, techniques etc.).
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Affiliation(s)
- Leonard Stojek
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Dan Bieler
- Department of Orthopedics and Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery and Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
- Department of Orthopedics and Trauma Surgery, Medical Faculty University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Anne Neubert
- Department of Orthopedics and Trauma Surgery, Medical Faculty University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
- TraumaEvidence @ German Society of Traumatology, Berlin, Germany
| | - Tobias Ahnert
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
- Helicopter Emergency Medical Service (HEMS) Christoph 3, Cologne, Germany
| | - Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany.
- Helicopter Emergency Medical Service (HEMS) Christoph 3, Cologne, Germany.
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Bhide M, Singh O, Juneja D, Goel A. Bedside ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure in nontraumatic neuro-critically ill patients. World J Crit Care Med 2023; 12:10-17. [PMID: 36683966 PMCID: PMC9846868 DOI: 10.5492/wjccm.v12.i1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/05/2022] [Accepted: 12/23/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Delay in treatment of raised intracranial pressure (ICP) leads to poor clinical outcomes. Optic nerve sheath diameter (ONSD) by ultrasonography (US-ONSD) has shown good accuracy in traumatic brain injury and neurosurgical patients to diagnose raised ICP. However, there is a dearth of data in neuro-medical intensive care unit (ICU) where the spectrum of disease is different.
AIM To validate the diagnostic accuracy of ONSD in non-traumatic neuro-critically ill patients.
METHODS We prospectively enrolled 114 patients who had clinically suspected raised ICP due to non-traumatic causes admitted in neuro-medical ICU. US-ONSD was performed according to ALARA principles. A cut-off more than 5.7 mm was taken as significantly raised. Raised ONSD was corelated with raised ICP on radiological imaging. Clinical history, general and systemic examination findings, SOFA and APACHE 2 score and patient outcomes were recorded.
RESULTS There was significant association between raised ONSD and raised ICP on imaging (P < 0.001). The sensitivity, specificity, positive and negative predictive value at this cut-off was 77.55%, 89.06%, 84.44% and 83.82% respectively. The positive and negative likelihood ratio was 7.09 and 0.25. The area under the receiver operating characteristic curves was 0.844. Using Youden’s index the best cut off value for ONSD was 5.75 mm. Raised ONSD was associated with lower age (P = 0.007), poorer Glasgow Coma Scale (P = 0.009) and greater need for surgical intervention (P = 0.006) whereas no statistically significant association was found between raised ONSD and SOFA score, APACHE II score or ICU mortality. Our limitations were that it was a single centre study and we did not perform serial measurements or ONSD pre- and post-treatment or procedures for raised ICP.
CONCLUSION ONSD can be used as a screening a test to detect raised ICP in a medical ICU and as a trigger to initiate further management of raised ICP. ONSD can be beneficial in ruling out a diagnosis in a low-prevalence population and rule in a diagnosis in a high-prevalence population.
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Affiliation(s)
- Madhura Bhide
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Amit Goel
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
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Vitiello L, Salerno G, De Bernardo M, D'Aniello O, Capasso L, Marotta G, Rosa N. Ultrasound Detection of Intracranial Hypertension in Brain Injuries. Front Med (Lausanne) 2022; 9:870808. [PMID: 35847791 PMCID: PMC9279702 DOI: 10.3389/fmed.2022.870808] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/13/2022] [Indexed: 11/17/2022] Open
Abstract
In recent years, the measurement of optic nerve sheath diameter with ultrasound to detect the presence of increased intracranial pressure has widely spread. It can be qualitatively and effectively used to identify intracranial hypertension. Intracranial pressure can rise due to acute injury, cerebral bleeding, hydrocephalus, brain tumors and other space-occupying abnormalities, and it is linked to a high death rate. The purpose of this review is to give a general overview of the most relevant scientific publications on ultrasonographic evaluation of the optic nerve in case of brain injuries published in the last 30 years, as well as to analyze the limits of the most extensively used B-scan approach. Fifty-two papers chosen from the PubMed medical database were analyzed in this review. Our findings revealed that ocular ultrasound is an useful diagnostic tool in the management of intracranial hypertension when it exceeds a certain value or after head trauma. As a result, an ultrasound of the optic nerve can be extremely helpful in guiding diagnosis and treatment. The blooming effect is one of the most critical restrictions to consider when using B-scan ultrasonography. Since amplitude-scan ultrasound, also known as A-scan, does not have this limit, these two diagnostic techniques should always be used together for a more full, accurate, and trustworthy ultrasound examination, ensuring more data objectivity.
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Affiliation(s)
- Livio Vitiello
- Eye Unit, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana,” University of Salerno, Salerno, Italy
| | - Giulio Salerno
- Eye Unit, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana,” University of Salerno, Salerno, Italy
| | - Maddalena De Bernardo
- Eye Unit, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana,” University of Salerno, Salerno, Italy
- *Correspondence: Maddalena De Bernardo
| | - Olga D'Aniello
- Eye Unit, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana,” University of Salerno, Salerno, Italy
| | - Luigi Capasso
- Corneal Transplant Unit, Azienda Sanitaria Locale Napoli 1, Naples, Italy
| | - Giuseppe Marotta
- Eye Unit, Azienda Ospedaliera Universitaria “San Giovanni di Dio e Ruggi D'Aragona”, Salerno, Italy
| | - Nicola Rosa
- Eye Unit, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana,” University of Salerno, Salerno, Italy
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