Bedside sonographic measurement of optic nerve sheath diameter as a predictor of intracranial pressure in ED

Published:February 12, 2016DOI:



      Ocular ultrasonography of optic nerve sheath diameter (ONSD) to determine intracranial pressure (ICP) has become favorable in recent years.


      To demonstrate the efficacy of ONSD measurement in determining the ICP increase due to nontraumatic events in the emergency department.


      A total of 100 patients with suspected nontraumatic intracranial event were enrolled in this prospective study. Patients were divided equally into 2 groups including 50 patients as group I with pathology on cranial computed tomography (CT) and group II with normal cranial CT. Prior to CT scans, patients underwent ONSD measurement by a radiologist using 11- and 14-MHz transducers.


      The ONSD values of groups I and II were 5.4 ± 1.1 and 4.1 ± 0.5 mm, respectively. Optic nerve sheath diameter was found to be larger on the side of lesion in patients with a lesion (P < .05). The cutoff value of the difference between ONSD values of both eyes in the presence of pathology was determined as 0.45 (sensitivity, 80%; specificity, 60%; the area under the curve, 0.794; 95% confidence interval, 0.705-0.883). The between-ONSD and midline shift size was statistically significant (r = 0.366, P = .009). The cutoff value of ONSD for the detection of midline shift was determined as 5.3 mm (sensitivity, 70%; specificity, 74%; the area under the curve, 0.728; 95% confidence interval, 0.585-0.871).


      Optic nerve sheath diameter measurement via bedside ocular ultrasonography in patients with suspected intracranial event in the emergency department is a useful method to determine ICP increase and its severity.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Gupta, G. and Miller, J.P. Intracranial pressure monitoring,

        • Frumin E.
        • Schlang J.
        • Wiechmann W.
        • Hata S.
        • Rosen S.
        • Anderson C.
        • et al.
        Prospective analysis of single operator sonographic optic nerve sheath diameter measurement for diagnosis of elevated intracranial pressure.
        West J Emerg Med. 2014; 15: 217-220
        • Birenbaum D.
        • Bancroft L.W.
        • Felsberg G.J.
        Imaging in acute stroke.
        West J Emerg Med. 2011; 12: 67-76
        • Blaivas M.
        • Theodoro D.
        • Sierzenski P.R.
        Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath.
        Acad Emerg Med. 2003; 10: 376-381
        • Wang L.
        • Feng L.
        • Yao Y.
        • Wang Y.
        • Chen Y.
        • Feng J.
        • et al.
        Optimal optic nerve sheath diameter threshold for the identification of elevated opening pressure on lumbar puncture in a Chinese population.
        PLoS One. 2015; 10: e0117939
        • Kristiansson H.
        • Nissborg E.
        • Bartek J.J.
        • Andresen M.
        • Reinstrup P.
        • Romner B.
        Measuring elevated intracranial pressure through noninvasive methods: a review of the literature.
        J Neurosurg Anesthesiol. 2013; 25: 372-385
        • Girisgin A.S.
        • Kalkan E.
        • Kocak S.
        • Cander B.
        • Gul M.
        • Semiz M.
        The role of optic nerve ultrasonography in the diagnosis of elevated intracranial pressure.
        Emerg Med J. 2007; 24: 251-254
        • Stengel D.
        • Rademacher G.
        • Ekkernkam A.
        • Güthoff C.
        • Mutze S.
        Emergency ultrasound–based algorithms for diagnosing blunt abdominal trauma.
        Cochrane Database Syst Rev. 2015; 14 ([CD004446]): 9
        • Cebicci H.
        • Salt O.
        • Gurbuz S.
        • Koyuncu S.
        • Bol O.
        Benefit of cardiac sonography for estimating the early term survival of the cardiopulmonary arrest patients.
        Hippokratia. 2014; 18: 125-129
        • Reissig A.
        • Copetti R.
        • Kroegel C.
        Current role of emergency ultrasound of the chest.
        Crit Care Med. 2011; 39: 839-845
        • Kozaci N.
        • Ay M.O.
        • Akcimen M.
        • Turhan G.
        • Sasmaz I.
        • Turhan S.
        • et al.
        Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures.
        Am J Emerg Med. 2015; 33: 67-71
        • Kozaci N.
        • Ay M.O.
        • Akcimen M.
        • Sasmaz I.
        • Turhan G.
        • Boz A.
        The effectiveness of bedside point-of-care ultrasonography in the diagnosis and management of metacarpal fractures.
        Am J Emerg Med. 2015; 33: 1468-1472
        • Hansen H.
        • Helmke K.
        The subarachnoid space surrounding the optic nerves. An ultrasound study of the optic nerve sheath.
        Surg Radiol Anat. 1996; 18: 323-328
        • Geeraerts T.
        • Launey Y.
        • Martin L.
        • Pottecher J.
        • Vigué B.
        • Duranteau J.
        • et al.
        Ultrasonography of the optic nervesheath may be useful for detecting raised intracranial pressure after severe brain injury.
        Intensive Care Med. 2007; 33: 1704-1711
        • Soldatos T.
        • Chatzimichail K.
        • Papathanasiou M.
        • Gouliamos A.
        Optic nerve sonography: a new window for the non-invasive evaluation of intracranial pressure in brain injury.
        Emerg Med J. 2009; 26: 630-634
        • Moretti R.
        • Pizzi B.
        Ultrasonography of the optic nerve in neurocritically ill patients.
        Acta Anaesthesiol Scand. 2011; 55: 644-652
        • Rajajee V.
        • Vanaman M.
        • Fletcher J.J.
        • Jacobs T.L.
        Optic nerve ultrasound for the detection of raised intracranial pressure.
        Neurocrit Care. 2011; 15: 506-515
        • Goel R.S.
        • Goyal N.K.
        • Dharap S.B.
        • Kumar M.
        • Gore M.A.
        Utility of optic nerve ultrasonography in head injury.
        Injury. 2008; 39: 519-524
        • Kimberly H.H.
        • Shah S.
        • Marill K.
        • Noble V.
        Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure.
        Acad Emerg Med. 2008; 15: 201-204
        • Sekhon M.S.
        • Griesdale D.E.
        • Robba C.
        • McGlashan N.
        • Needham E.
        • Walland K.
        • et al.
        Optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury.
        Intensive Care Med. 2014; 40: 1267-1274
        • Geeraerts T.
        • Newcombe V.F.
        • Coles J.P.
        • Abate M.G.
        • Perkes I.E.
        • Hutchinson P.J.
        • et al.
        Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure.
        Crit Care. 2008; 12: R114
        • Shirodkar C.G.
        • Munta K.
        • Rao S.M.
        • Mahesh M.U.
        Correlation of measurement of optic nerve sheath diameter using ultrasound with magnetic resonance imaging.
        Indian J Crit Care Med. 2015; 19: 466-470
        • Soldatos T.
        • Karakitsos D.
        • Chatzimichail K.
        • Papathanasiou M.
        • Gouliamos A.
        • Karabinis A.
        Optic nerve sonography in the diagnostic evaluation of adult brain injury.
        Crit Care. 2008; 12: R67
        • Shirodkar C.G.
        • Rao S.M.
        • Mutkule D.P.
        • Harde Y.R.
        • Venkategowda P.M.
        • Mahesh M.U.
        Optic nerve sheath diameter as a marker for evaluation and prognostication of intracranial pressure in Indian patients: an observational study.
        Indian J Crit Care Med. 2014; 18: 728-734
        • Govil D.
        • Srinivasan S.
        Optic nerve sheath diameter measurement using bedside ultrasound: is it accurate?.
        Indian J Crit Care Med. 2015; 19: 443-445
        • Maude R.R.
        • Hossain M.A.
        • Hassan M.U.
        • Osbourne S.
        • Sayeed K.L.
        • Karim M.R.
        • et al.
        Transorbital sonographic evaluation of normal optic nerve sheath diameter in healthy volunteers in Bangladesh.
        PLoS One. 2013; 8: e81013
        • Chan P.Y.N.
        • Mok K.L.
        Transorbital sonographic evaluation of optic nerve sheath diameter in normal Hong Kong Chinese adults.
        Hong Kong j emerg med. 2008; 15: 197-204
        • Kennedy S.A.
        • Noble J.
        • Wong A.M.F.
        Examining the pupils.
        CMAJ. 2013; 185: E424
        • Chiewvit P.
        • Tritakarn S.O.
        • Nanta-aree S.
        • Suthipongchai S.
        Degree of midline shift from CT scan predicted outcome in patients with head injuries.
        J Med Assoc Thai. 2010; 93: 99-107
        • Motuel J.
        • Biette I.
        • Srairi M.
        • Mrozek S.
        • Kurrek M.M.
        • Chaynes P.
        Assessment of brain midline shift using sonography in neurosurgical ICU patients.
        Crit Care. 2014; 18: 676
        • Kazdal H.
        • Kanat A.
        • Findik H.
        • Sen A.
        • Ozdemir B.
        • Batcik O.E.
        • et al.
        Transorbital ultra-sonographic measurement of optic nerve sheath diameter for intracranial midline shift in patients with head trauma.
        World Neurosurg. 2015; ([pii: S1878-8750(15)01358-3])