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Oprtic1.nerve sheath

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This document discusses using optic nerve sheath diameter (ONSD) measurements via ultrasound as a tool to assess increased intracranial pressure (ICP). It provides background on ONSD anatomy and evidence that ONSD changes mimic ICP changes. Studies show ONSD has high sensitivity and specificity for detecting elevated ICP compared to invasive monitoring. The document proposes a prospective study measuring ONSD in patients with conditions like end-stage liver disease, end-stage renal disease, and hypertensive crises to see if ONSD decreases after treatment and normalize, indicating reduced ICP. It suggests ONSD could help predict complications like dialysis disequilibrium syndrome.

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Optic Nerve Sheath Diameter ( ONSD ) in Increased intracnial Pressures ( ICP ) A new tool in the Ultrasound Era
Causes of ICP Obstruction CSF flow and/or Mass effect: Hydrocephalus absorption : Malignancy Extensive meningeal disease (e.g., infectious, CVA with edema Cerebral contusions carcinomatous, subdural or epidural hematoma granulomatous ) abscess Superior sagittal sinus (decreased absorption) Diffuse Encephalopathies: Acute liver failure Increased CSF production : Hypertensive Encephalopthy Meningitis High Altitude cerebral edema Subarachnoid hemorrhage, Uremic Encephalopathy PseudotumorCerebri
Why look at ONSD? How do we currently assess EICP : Non-specific signs and symptoms Imaging CT scan/MRI Pulsatliity index Invasive monitoring Papilledema
CT and ICP Moving patients Repeat for head CT one third of trauma need repeat head CT looking for ICP . Radiographic delay? Initial head CTs of 100 head injured trauma patients evaluated by group of 12 radiologists : Sensitivity 83% , Specifity 78%
Invasive ICP measurments Gold standard External Ventricular Device Comlipcated/ invasive procedure Risks Infection, parenchymal injury , bleeding Bleeding diasthesis
Oprtic1.nerve sheath
Gold standard for ICP External Ventricular Device ( EVD )
Papilledema Operator dependant Delayed manifestation: - 24 hrs May persist for several days to weeks after treatment
Papilledema ? Both are Normal
Oprtic1.nerve sheath
Outline Basic anatomy of the Optic nerve and its sheath How to measure ONSD? Rationale and evidence for using the ONSD for Increased intracerebral pressure ( ICP ) Uses and rationale in different clinical settings : ESRD , ESLD ,HTN crises and altitude sickness
ONSD basic anatomy Optic Nerve: White matter tract direct extension of the CNS surrounded by CSF Sensitive to changes to CSF flow and intracerebral pressures ( ICP )
Intra-orbital CSF h Intracranial CSF
Optic Nerve
ONSD history British opthalmologistHayreh The mechanism of papiledema from increased ICP Placed inflatable balloons in the brain of monkeys
Oprtic1.nerve sheath
Oprtic1.nerve sheath
Oprtic1.nerve sheath
Rapid response ONSD Hansen et al : Infused NS into CSF Changes in ONSD occurred within minutes Mean change of 1.97mm or around 83% increase Relieving pressure rapid decrease in size Exception was with prolonged exposure to very high pressures showed a delay in regression Changes in ONSD mimics changes in ICP Acta Ophthalmol. 2011 Sep;89(6):e528-32.
How do we measure the ONSD? 3-7.5Mhz Probe Supine position at around 20 degrees phlebotactic axis Perpendicular axis at 3mm behind ON entry point 2 reading on each eye Probe applied directly over the eyelid Cutoff 5mm or 5.7mm
3mm ONSD
3mm ONSD
Lens Vitreous A-A 0.3cm B-B 0.62 cm
ONSD False Positive Emerg Med J 2007;24:251254. doi: 10.1136/emj.2006.040931 Volume status Emerg Med J 2007;24:251254. doi: 10.1136/emj.2006.040931 Abdullah SadikGirisgin, ErdalKalkan, SedatKocak, BasarCander, MehmetGul, Mustafa Semiz
Reproducible results 54 patients: 28 confirmed EICP via CT scan 26 no evidence of EICP
Oprtic1.nerve sheath
ONSD evidence based approach Most studies Trauma or neurosurgical patients 3 major studies on ONSD ( briefly )
ONSD evidence Prospective study on 26 ED patients ONSD cutoff > 0.5 cm All had CT scans Emer Med J published online August 15, 2010 ,Robert Major, Simon Girling and Adrian Boyleg
永永閣100% NPV95% Sens 86% Sepcificity 99% for EICP ONSD cutoff >5mm
ONSD evidence Small sample size Non-trauma GSC: 8 Compared to CT scan
Invasive and non-invasive comparison 76 patients Pulsatility index 26 Control 18 32 Moderate Severe Invasive ICP Moderate Marshall score I and GSC > 8 monitoring Severe Marshall score >I and GCS < 8
76 patients Brain CT injury scale No CT done Normal CT Abnormal CT 18% 82% ONSD cutoff 5.7mm
Non-invasive Invasive Monitoring monitoring
ROC :0.93 Sens : 74% Spec: 99% ONSD cutoff > 5.7mm TheodorosSoldtos, Optic nerve sonography in the diagnostic Evaluation of adult brain injury, Critical care 2008;12 R 67
Prospective Blind observational trial 31 ICU patients with severe TBI GSC<8 16 EICP 15 Normal ICP All patients underwent invasive ICP monitoring Intensive Care Med (2007) 33:17041711, T. Geeraerts () 揃 Y. Launey 揃 L. Martin 揃J. Pottecher 揃 B. Vigu辿 揃 J. Duranteau 揃D. Benhamou
5.7 mm
ROC: 0.96 Sens: 91% Spec: 94% Thomas Geerats M.D, Ultrasonography of Optic nerve Sheath may be useful in detecting raised ICP After head trauma. Intensive care Medicine 2007, 33:1704-1711
ONSD evidence conclusion Cutoff> 5.7mm for EICP Sensitivity of around 93% Specificity: 96% 5-5.7mm Sensitivity is maintained however Specificity declines to 83% Screening tool Surrogate marker for EICP
ICP causes Obstruction CSF flow and/or Diffuse Encephalopathies: absorption : ESLD ESRD Hydrocephalus Hypertensive Encephalopthy High Altitude cerebral edema Extensive meningeal disease granulo (e.g., infectious, carcinomatous, matous ) Mass effect: Superior sagittal sinus (decreased Malignancy absorption) CVA with edema Increased CSF production : Cerebral contusions Meningitis Subdural or epidural hematoma Subarachnoid hemorrhage, Abscess
Study Prospective observational/descriptive analysis Medicine patient admitted to general medicine floor , MICU ESLD / ESRD / HTN crisis No head / ocular trauma No other cause for EICP Comparing ONSD diameter of non-encephalopathy v/s encephalopathy pre-treatment /24hrs post-treatment Convenience sample
Hypothesis Absolute value of ONSD would be high among the encephalopathic group and would normalize after treatment Statistically significant change in ONSD pre and post treatment
Definitions EICP: - > 20 mmHg, If invasive monitoring available . Radiographic evidence of raised ICP as determined by CT ONSD : cut-off of 5.7 mm to define enlarged ONSD , ESLD and Uremia straightforward HTN encephalopathy ? Unclear and vague definition.
Method 7-12 MHz while patient is at 20 degree angle 2 measurements from each eye ( for a total of 4 per patient ) Measurements will be taken both prior and within 24hrs after treatment
ESLD and ICP Fulminant hepatic failure 80% EICP Ammonia and Manganese astrocyte edema Chronic ESLD EICP only in stage IV hepatic encephalopathy
N=24 No Encephalopathy Encephalopathy N=10 N=14 Stage I Stage II Stage III Stage IV N=2 N=5 N=3 N=0
Pretreament ESLD 10 Stage I ONSD in mm 9 Stage II 8 Stage III 7 6 5.7mm 5 4 3 2 1 N= 14 N=10 0 Encephalopathy No Encephalopathy With Encephalopathy
Post-treament ESLD 10 Stage I ONSD in mm 9 Stage II 8 Stage III 7 Relative decrease 57% 6 5.7mm 5 4 3 2 1 N= 14 N= 10 0 Encephalopathy No Encephalopathy With Encephalopathy
Summary ESLD Pretreatment Post-treatment 10 ONSD in mm 10 Stage I 9 9 Stage II 8 8 7 7 Stage III 6 6 5.7mm 5 5 4 4 3 3 2 2 1 1 0 N= 8 0 N= 8 N= 14 N= 14 No Encephalopathy With No With Encephalopathy Encephalopathy Encephalopathy
ESRD and ICP Dialysis Dysequilibrium Syndrome Very high BUN > 110
Pretreatment ESRD Pretreatment Post-treatment 10 ONSD in mm 9 8 7 46 %decrease 63% decrease 6 5 4 3 2 N= 13 N= 4 1 No With No With 0 Encephalopathy Encephalopathy Encephalopathy Encephalopathy yes No 1/9/02
Data analysis Relative decrease in ONSD in both groups was significant NO encephalopathy: - 46% With Encephalopathy: - 63% Other etiologies for increase ONSD : Volume status HTN Utility in predicting DDS?
HTN crisis Most common manifestation are neurologic : 44% with HTN emergency have neurologic manifestations 16% HTN encephalopathy Clinically subtle Pathophysiology Breakthrough autoregulation CT head to r/o CVA helpful however in HTN encephalopathy not so much
Oprtic1.nerve sheath
Oprtic1.nerve sheath
HTN crisis Pretreatment Post-treatment 10 ONSD in mm Encephalopathic 9 5.2mm 7.2mm 8 7 57% decrease 68% decrease 6 5 4 3 2 N= 11 N= 5 1 Uncontrolled HTN emergency Uncontrolled HTN emergency 0 HTN HTN yes No 1/9/02
Data analysis Uncontrolled HTN had rather high ONSD subclinical EICP Relative size decrease : 57% in Uncontrolled HTN 68% HTN emergency
High altitude sickness No data yet 14ers ONSD at base , peak , base Symptoms of Altitude sickness ONSD absolute value and change
Conclusion ONSD: Reliable surrogate marker for EICP Quick bedside evaluation that competes with CT scans Reproducible results easy to learn Large area of research Downfalls: - Etiology
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Oprtic1.nerve sheath

  • 1. Optic Nerve Sheath Diameter ( ONSD ) in Increased intracnial Pressures ( ICP ) A new tool in the Ultrasound Era
  • 2. Causes of ICP Obstruction CSF flow and/or Mass effect: Hydrocephalus absorption : Malignancy Extensive meningeal disease (e.g., infectious, CVA with edema Cerebral contusions carcinomatous, subdural or epidural hematoma granulomatous ) abscess Superior sagittal sinus (decreased absorption) Diffuse Encephalopathies: Acute liver failure Increased CSF production : Hypertensive Encephalopthy Meningitis High Altitude cerebral edema Subarachnoid hemorrhage, Uremic Encephalopathy PseudotumorCerebri
  • 3. Why look at ONSD? How do we currently assess EICP : Non-specific signs and symptoms Imaging CT scan/MRI Pulsatliity index Invasive monitoring Papilledema
  • 4. CT and ICP Moving patients Repeat for head CT one third of trauma need repeat head CT looking for ICP . Radiographic delay? Initial head CTs of 100 head injured trauma patients evaluated by group of 12 radiologists : Sensitivity 83% , Specifity 78%
  • 5. Invasive ICP measurments Gold standard External Ventricular Device Comlipcated/ invasive procedure Risks Infection, parenchymal injury , bleeding Bleeding diasthesis
  • 7. Gold standard for ICP External Ventricular Device ( EVD )
  • 8. Papilledema Operator dependant Delayed manifestation: - 24 hrs May persist for several days to weeks after treatment
  • 9. Papilledema ? Both are Normal
  • 11. Outline Basic anatomy of the Optic nerve and its sheath How to measure ONSD? Rationale and evidence for using the ONSD for Increased intracerebral pressure ( ICP ) Uses and rationale in different clinical settings : ESRD , ESLD ,HTN crises and altitude sickness
  • 12. ONSD basic anatomy Optic Nerve: White matter tract direct extension of the CNS surrounded by CSF Sensitive to changes to CSF flow and intracerebral pressures ( ICP )
  • 13. Intra-orbital CSF h Intracranial CSF
  • 15. ONSD history British opthalmologistHayreh The mechanism of papiledema from increased ICP Placed inflatable balloons in the brain of monkeys
  • 19. Rapid response ONSD Hansen et al : Infused NS into CSF Changes in ONSD occurred within minutes Mean change of 1.97mm or around 83% increase Relieving pressure rapid decrease in size Exception was with prolonged exposure to very high pressures showed a delay in regression Changes in ONSD mimics changes in ICP Acta Ophthalmol. 2011 Sep;89(6):e528-32.
  • 20. How do we measure the ONSD? 3-7.5Mhz Probe Supine position at around 20 degrees phlebotactic axis Perpendicular axis at 3mm behind ON entry point 2 reading on each eye Probe applied directly over the eyelid Cutoff 5mm or 5.7mm
  • 23. Lens Vitreous A-A 0.3cm B-B 0.62 cm
  • 24. ONSD False Positive Emerg Med J 2007;24:251254. doi: 10.1136/emj.2006.040931 Volume status Emerg Med J 2007;24:251254. doi: 10.1136/emj.2006.040931 Abdullah SadikGirisgin, ErdalKalkan, SedatKocak, BasarCander, MehmetGul, Mustafa Semiz
  • 25. Reproducible results 54 patients: 28 confirmed EICP via CT scan 26 no evidence of EICP
  • 27. ONSD evidence based approach Most studies Trauma or neurosurgical patients 3 major studies on ONSD ( briefly )
  • 28. ONSD evidence Prospective study on 26 ED patients ONSD cutoff > 0.5 cm All had CT scans Emer Med J published online August 15, 2010 ,Robert Major, Simon Girling and Adrian Boyleg
  • 29. 永永閣100% NPV95% Sens 86% Sepcificity 99% for EICP ONSD cutoff >5mm
  • 30. ONSD evidence Small sample size Non-trauma GSC: 8 Compared to CT scan
  • 31. Invasive and non-invasive comparison 76 patients Pulsatility index 26 Control 18 32 Moderate Severe Invasive ICP Moderate Marshall score I and GSC > 8 monitoring Severe Marshall score >I and GCS < 8
  • 32. 76 patients Brain CT injury scale No CT done Normal CT Abnormal CT 18% 82% ONSD cutoff 5.7mm
  • 33. Non-invasive Invasive Monitoring monitoring
  • 34. ROC :0.93 Sens : 74% Spec: 99% ONSD cutoff > 5.7mm TheodorosSoldtos, Optic nerve sonography in the diagnostic Evaluation of adult brain injury, Critical care 2008;12 R 67
  • 35. Prospective Blind observational trial 31 ICU patients with severe TBI GSC<8 16 EICP 15 Normal ICP All patients underwent invasive ICP monitoring Intensive Care Med (2007) 33:17041711, T. Geeraerts () 揃 Y. Launey 揃 L. Martin 揃J. Pottecher 揃 B. Vigu辿 揃 J. Duranteau 揃D. Benhamou
  • 37. ROC: 0.96 Sens: 91% Spec: 94% Thomas Geerats M.D, Ultrasonography of Optic nerve Sheath may be useful in detecting raised ICP After head trauma. Intensive care Medicine 2007, 33:1704-1711
  • 38. ONSD evidence conclusion Cutoff> 5.7mm for EICP Sensitivity of around 93% Specificity: 96% 5-5.7mm Sensitivity is maintained however Specificity declines to 83% Screening tool Surrogate marker for EICP
  • 39. ICP causes Obstruction CSF flow and/or Diffuse Encephalopathies: absorption : ESLD ESRD Hydrocephalus Hypertensive Encephalopthy High Altitude cerebral edema Extensive meningeal disease granulo (e.g., infectious, carcinomatous, matous ) Mass effect: Superior sagittal sinus (decreased Malignancy absorption) CVA with edema Increased CSF production : Cerebral contusions Meningitis Subdural or epidural hematoma Subarachnoid hemorrhage, Abscess
  • 40. Study Prospective observational/descriptive analysis Medicine patient admitted to general medicine floor , MICU ESLD / ESRD / HTN crisis No head / ocular trauma No other cause for EICP Comparing ONSD diameter of non-encephalopathy v/s encephalopathy pre-treatment /24hrs post-treatment Convenience sample
  • 41. Hypothesis Absolute value of ONSD would be high among the encephalopathic group and would normalize after treatment Statistically significant change in ONSD pre and post treatment
  • 42. Definitions EICP: - > 20 mmHg, If invasive monitoring available . Radiographic evidence of raised ICP as determined by CT ONSD : cut-off of 5.7 mm to define enlarged ONSD , ESLD and Uremia straightforward HTN encephalopathy ? Unclear and vague definition.
  • 43. Method 7-12 MHz while patient is at 20 degree angle 2 measurements from each eye ( for a total of 4 per patient ) Measurements will be taken both prior and within 24hrs after treatment
  • 44. ESLD and ICP Fulminant hepatic failure 80% EICP Ammonia and Manganese astrocyte edema Chronic ESLD EICP only in stage IV hepatic encephalopathy
  • 45. N=24 No Encephalopathy Encephalopathy N=10 N=14 Stage I Stage II Stage III Stage IV N=2 N=5 N=3 N=0
  • 46. Pretreament ESLD 10 Stage I ONSD in mm 9 Stage II 8 Stage III 7 6 5.7mm 5 4 3 2 1 N= 14 N=10 0 Encephalopathy No Encephalopathy With Encephalopathy
  • 47. Post-treament ESLD 10 Stage I ONSD in mm 9 Stage II 8 Stage III 7 Relative decrease 57% 6 5.7mm 5 4 3 2 1 N= 14 N= 10 0 Encephalopathy No Encephalopathy With Encephalopathy
  • 48. Summary ESLD Pretreatment Post-treatment 10 ONSD in mm 10 Stage I 9 9 Stage II 8 8 7 7 Stage III 6 6 5.7mm 5 5 4 4 3 3 2 2 1 1 0 N= 8 0 N= 8 N= 14 N= 14 No Encephalopathy With No With Encephalopathy Encephalopathy Encephalopathy
  • 49. ESRD and ICP Dialysis Dysequilibrium Syndrome Very high BUN > 110
  • 50. Pretreatment ESRD Pretreatment Post-treatment 10 ONSD in mm 9 8 7 46 %decrease 63% decrease 6 5 4 3 2 N= 13 N= 4 1 No With No With 0 Encephalopathy Encephalopathy Encephalopathy Encephalopathy yes No 1/9/02
  • 51. Data analysis Relative decrease in ONSD in both groups was significant NO encephalopathy: - 46% With Encephalopathy: - 63% Other etiologies for increase ONSD : Volume status HTN Utility in predicting DDS?
  • 52. HTN crisis Most common manifestation are neurologic : 44% with HTN emergency have neurologic manifestations 16% HTN encephalopathy Clinically subtle Pathophysiology Breakthrough autoregulation CT head to r/o CVA helpful however in HTN encephalopathy not so much
  • 55. HTN crisis Pretreatment Post-treatment 10 ONSD in mm Encephalopathic 9 5.2mm 7.2mm 8 7 57% decrease 68% decrease 6 5 4 3 2 N= 11 N= 5 1 Uncontrolled HTN emergency Uncontrolled HTN emergency 0 HTN HTN yes No 1/9/02
  • 56. Data analysis Uncontrolled HTN had rather high ONSD subclinical EICP Relative size decrease : 57% in Uncontrolled HTN 68% HTN emergency
  • 57. High altitude sickness No data yet 14ers ONSD at base , peak , base Symptoms of Altitude sickness ONSD absolute value and change
  • 58. Conclusion ONSD: Reliable surrogate marker for EICP Quick bedside evaluation that competes with CT scans Reproducible results easy to learn Large area of research Downfalls: - Etiology

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