Transcranial sonographic assessment of the third ventricle in neuro-ICU patients to detect hydrocephalus: a diagnostic reliability pilot study

Rémy Widehem, Paul Bory, Frédéric Greco, Frédérique Pavillard, Kévin Chalard, Alexandre Mas, Flora Djanikian, Julie Carr, Nicolas Molinari, Samir Jaber, Pierre-François Perrigault, Gerald Chanques, Rémy Widehem, Paul Bory, Frédéric Greco, Frédérique Pavillard, Kévin Chalard, Alexandre Mas, Flora Djanikian, Julie Carr, Nicolas Molinari, Samir Jaber, Pierre-François Perrigault, Gerald Chanques

Abstract

Background: Transcranial sonography is a point-of-care tool recommended in intensive care units (ICU) to monitor brain injured patients. Objectives of the study was to assess feasibility and reliability of the third ventricle (V3) diameter measurement using transcranial sonography (TCS) compared to brain computed-tomography (CT), the gold standard measurement, and to measure the TCS learning curve.

Design: prospective study, in a 16-bed neurological ICU in an academic hospital. Every consecutive brain injured adult patient, who required a brain CT and TCS monitoring were included. The V3 diameter was blindly measured by TCS and CT. Intraclass correlation coefficient (ICC) and Bland-Altman plot were used to assess the reliability and agreement between TCS and CT V3 measurements. Diagnosis performance of the V3 diameter using TCS to detect hydrocephalus was measured. Absolute difference between V3 measurement by residents and experts was measured consecutively to assess the learning curve.

Results: Among the 100 patients included in the study, V3 diameter could be assessed in 87 patients (87%) from at least one side of the skull. Both temporal windows were available in 70 patients (70%). The ICC between V3 diameter measured by TCS and CT was 0.90 [95% CI 0.84-0.93] on the right side, and 0.92 [0.88-0.95] on the left side. In Bland-Altman analysis, mean difference, standard deviation, 95% limits of agreement were 0.36, 1.52, - 2.7 to 3.3 mm, respectively, on the right side; 0.25, 1.47, - 2.7 to 3.1 mm, respectively, on the left side. Among the 35 patients with hydrocephalus, V3 diameters could be measured by TCS in 31 patients (89%) from at least one side. Hydrocephalus was, respectively, excluded, confirmed, or inconclusive using TCS in 35 (40%), 25 (29%) and 27 (31%) of the 87 assessable patients. After 5 measurements, every resident reached a satisfactory measurement compared to the expert operator.

Conclusion: TCS allows rapid, simple and reliable V3 diameter measurement compared with the gold standard in neuro-ICU patients. Aside from sparing irradiating procedures and transfers to the radiology department, it may especially increase close patient monitoring to detect clinically occult hydrocephalus earlier. Further studies are needed to measure the potential clinical benefit of this method.

Trial registration: ClinicalTrials.gov ID: NCT02830269.

Keywords: Hydrocephalus; Neurocritical care; Point of care; Sonography; Third ventricle.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Sonographic view of V3 and the corresponding anatomic diagram. The third ventricle was identified as a double hyperechogenic image over the midbrain with the diencephalon on both sides
Fig. 2
Fig. 2
V3 diameters measured by TCS and CT according to Bland–Altman diagram. Bland–Altman plots show the agreement between TCS and CT for V3 diameter measurements for each side of measurement. Bars lines represent 95% limits of agreement, and blue lines represent the mean difference. Mean difference between CT and TCS was 0.36 mm (standard deviation (SD) 1.52 mm, 95% limits of agreement (95% LOA) − 2.7 mm to 3.3 mm) for the right side, and 0.25 mm (SD 1.47 mm, 95% LOA − 2.7 mm to 3.1 mm) for the left side
Fig. 3
Fig. 3
a Receiver operating characteristic (ROC) curve of V3 diameter measured by TCS to detect hydrocephalus diagnosed on CT. The ROC curve represents the specificity and sensitivity of TCS to diagnose hydrocephalus. AUC was 0.91% [95% CI 0.85–0.98%], the estimated best threshold was at 6.25 mm, with a specificity of 0.79 and a sensibility of 0.88. Positive predictive value (PPV) and negative predictive value (NPV) are provided for thresholds on either side of the grey zone (see Fig. 3b). b Two-curve sensitivity/specificity representation of grey zone for V3 diameter measured by TCS, associated with a hydrocephalus diagnosed on CT. We defined a grey zone for cut-offs with a sensitivity lower than 90% and a specificity lower than 90% (diagnosis tolerance of 10%). On either side of these cut-offs, patients were assigned to a low-risk or a high-risk. The diagnosis of hydrocephalus was thus excluded in 35 (40%) patients with a V3 diameter < 5.2 mm and confirmed in 25 (29%) patients with a V3 diameter > 7.7 mm. TCS was inconclusive in 27/87 (31%) patients. The V3 measurement from the right side was included for these analyses because right side was the most frequently assessable side. The left side was included when V3 was not assessable from right side
Fig. 4
Fig. 4
Learning curves for V3 measurement by TCS. Plots represent the mean absolute difference between the V3 measurement by the 9 participating residents and the V3 measurement by an expert physician. Bars represent the standard errors of the mean. Full line represents right side, and dotted line the left side. Red line represents the 1-mm threshold which was the a priori defined learning objective

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