Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure

Thomas Geeraerts, Virginia F J Newcombe, Jonathan P Coles, Maria Giulia Abate, Iain E Perkes, Peter J A Hutchinson, Jo G Outtrim, Dot A Chatfield, David K Menon, Thomas Geeraerts, Virginia F J Newcombe, Jonathan P Coles, Maria Giulia Abate, Iain E Perkes, Peter J A Hutchinson, Jo G Outtrim, Dot A Chatfield, David K Menon

Abstract

Introduction: The dural sheath surrounding the optic nerve communicates with the subarachnoid space, and distends when intracranial pressure is elevated. Magnetic resonance imaging (MRI) is often performed in patients at risk for raised intracranial pressure (ICP) and can be used to measure precisely the diameter of optic nerve and its sheath. The objective of this study was to assess the relationship between optic nerve sheath diameter (ONSD), as measured using MRI, and ICP.

Methods: We conducted a retrospective blinded analysis of brain MRI images in a prospective cohort of 38 patients requiring ICP monitoring after severe traumatic brain injury (TBI), and in 36 healthy volunteers. ONSD was measured on T2-weighted turbo spin-echo fat-suppressed sequence obtained at 3 Tesla MRI. ICP was measured invasively during the MRI scan via a parenchymal sensor in the TBI patients.

Results: Measurement of ONSD was possible in 95% of cases. The ONSD was significantly greater in TBI patients with raised ICP (>20 mmHg; 6.31 +/- 0.50 mm, 19 measures) than in those with ICP of 20 mmHg or less (5.29 +/- 0.48 mm, 26 measures; P < 0.0001) or in healthy volunteers (5.08 +/- 0.52 mm; P < 0.0001). There was a significant relationship between ONSD and ICP (r = 0.71, P < 0.0001). Enlarged ONSD was a robust predictor of raised ICP (area under the receiver operating characteristic curve = 0.94), with a best cut-off of 5.82 mm, corresponding to a negative predictive value of 92%, and to a value of 100% when ONSD was less than 5.30 mm.

Conclusions: When brain MRI is indicated, ONSD measurement on images obtained using routine sequences can provide a quantitative estimate of the likelihood of significant intracranial hypertension.

Figures

Figure 1
Figure 1
Methodology to measure ONSD and OND. OND, optic nerve diameter; ONSD, optic nerve sheath diameter.
Figure 2
Figure 2
Parenchymal ICP versus ONSD and OND. Presented is the relationship between parenchymal ICP and (a) ONSD and (b) OND. Linear regression analysis identified a strong and significant relationship between ICP and ONSD. ICP, intracranial pressure; OND, optic nerve diameter; ONSD, optic nerve sheath diameter.
Figure 3
Figure 3
ROC curves for ONSD and OND with respect to raised ICP. 'Raised ICP' is defined as an ICP above 20 mmHg identified during T2-weighted magnetic resonance imaging. ICP, intracranial pressure; OND, optic nerve diameter; ONSD, optic nerve sheath diameter; ROC, receiver operating characteristic.
Figure 4
Figure 4
Agreement between observers in measurement of ONSD. Presented is a Bland-Altman [37] graphical representation. ONSD, optic nerve sheath diameter; SD, standard deviation.

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