Neurocritical Care

, 11:406

Reliability of Optic Nerve Ultrasound for the Evaluation of Patients with Spontaneous Intracranial Hemorrhage

  • Riccardo Moretti
  • Barbara Pizzi
  • Fabrizio Cassini
  • Nicoletta Vivaldi
Take Notice Technology



The aim of our study is to confirm the reliability of optic nerve ultrasound as a method to detect intracranial hypertension in patients with spontaneous intracranial hemorrhage, to assess the reproducibility of the measurement of the optic nerve sheath diameter (ONSD), and to verify that ONSD changes concurrently with intracranial pressure (ICP) variations.


Sixty-three adult patients with subarachnoid hemorrhage (n = 34) or primary intracerebral hemorrhage (n = 29) requiring sedation and invasive ICP monitoring were enrolled in a 10-bed multivalent ICU. ONSD was measured 3 mm behind the globe through a 7.5-MHz ultrasound probe. Mean binocular ONSD was used for statistical analysis. ICP values were registered simultaneously to ultrasonography. Twenty-eight ONSDs were measured consecutively by two different observers, and interobserver differences were calculated. Twelve coupled measurements were taken before and within 1 min after cerebrospinal fluid (CSF) drainage to control elevated ICP.


Ninety-four ONSD measurements were analyzed. 5.2 mm proved to be the optimal ONSD cut-off point to predict raised ICP (>20 mmHg) with 93.1% sensitivity (95% CI: 77.2–99%) and 73.85% specificity (95% CI: 61.5–84%). ONSD–ICP correlation coefficient was 0.7042 (95% CI for r = 0.5850–0.7936). The median interobserver ONSD difference was 0.25 mm. CSF drainage to control elevated ICP caused a rapid and significant reduction of ONSD (from 5.89 ± 0.61 to 5 ± 0.33 mm, P < 0.01).


Our investigation confirms the reliability of optic nerve ultrasound as a non-invasive method to detect elevated ICP in intracranial hemorrhage patients. ONSD measurements proved to have a good reproducibility. ONSD changes almost concurrently with CSF pressure variations.


Optic nerve sheath diameter Ultrasound Intracranial hemorrhage Intracranial pressure 


  1. 1.
    Hayreh SS. Pathogenesis of oedema of the optic disc (papilloedema). Br J Opthalmol. 1964;48:522–43.CrossRefGoogle Scholar
  2. 2.
    Liu D, Kahn M. Measurement and relationship of subarachnoid pressure of the optic nerve to intracranial pressures in fresh cadavers. Am J Opthalmol. 1993;116:548–56.Google Scholar
  3. 3.
    Helmke K, Hansen HC. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. I. Experimental study. Pediatr Radiol. 1996;26:701–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Helmke K, Hansen HC. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. II. Patient study. Pediatr Radiol. 1996;26:706–10.CrossRefPubMedGoogle Scholar
  5. 5.
    Helmke K, Burdelski M, Hansen H. Detection and monitoring of intracranial pressure dysregulation in liver failure by ultrasound. Transplantation. 2000;70(2):392–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Newman WD, Hollman AS, Dutton GN, Carachi R. Measurement of optic nerve sheath diameter by ultrasound: a means of detecting acute raised intracranial pressure in hydrocephalus. Br J Opthalmol. 2002;86:1109–13.CrossRefGoogle Scholar
  7. 7.
    Tayal VS, Neulander M, Norton HJ, Foster T, Saunders T, Blavias M. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med. 2007;49:508–14.CrossRefPubMedGoogle Scholar
  8. 8.
    Blavias M, Theodoro DL, Sierzenski P. Elevated intracranial pressure detected by bedside emergency ultrasound of the optic nerve sheath. Acad Emerg Med. 2003;10:376–81.CrossRefGoogle Scholar
  9. 9.
    Goel RS, Goyal NK, Dharap SB, Kumar M, Gore MA. Utility of optic nerve ultrasonography in head injury. Injury. 2008;39(5):519–24.CrossRefPubMedGoogle Scholar
  10. 10.
    Hansen HC, Helmke K. Validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests. J Neurosurg. 1997;87:34–40.CrossRefPubMedGoogle Scholar
  11. 11.
    Geeraerts T, Launey Y, Martin L, Kumar M, Gore MA. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med. 2007;33:1704–11.CrossRefPubMedGoogle Scholar
  12. 12.
    Harbison Kimberly H, Shah S, Marill K, Noble V. Correlation of optic nerve sheath with direct measurement of intracranial pressure. Acad Emerg Med. 2008;15:201–4.CrossRefGoogle Scholar
  13. 13.
    Geeraerts T, Merceron S, Benhamou D, Vigué B, Duranteau J. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med. 2008;34(11):2062–7.CrossRefPubMedGoogle Scholar
  14. 14.
    Soldatos T, Karakistos D, Chatzimichail K, Papathanasiou M, Gouliamos A, Karabinis A. Optic nerve sonography in the diagnostic evaluation of adult brain injury. Crit Care. 2008;12(3):150.CrossRefGoogle Scholar
  15. 15.
    Moretti R, Pizzi B. Optic nerve ultrasound for detection of intracranial hypertension in intracranial hemorrhage patients. J Neurosurg Anesthesiol. 2009;21(1):16–20.CrossRefPubMedGoogle Scholar
  16. 16.
    Copetti R, Cattarossi L. Optic nerve ultrasound: artifacts and real images. Intensive Care Med [On-line] 2009. doi:10.1007/s00134-009-1494-4.
  17. 17.
    Romagnulo L, Tayal V, Tomazewski C, Saunders T, Northon J. Optic nerve sheath does not change with patient position. Am J Emerg Med. 2005;23:686–8.CrossRefGoogle Scholar
  18. 18.
    Lichtenstein D. Optic nerve and intracranial hypertension. In: Lichtenstein D, editor. General ultrasound in the critically ill. Berlin: Springer; 2007. p. 152–4.Google Scholar
  19. 19.
    Geeraerts T, Bergès O, Merceron S, et al. Reply to Copetti and Cattarossi. Intensive Care Med [On-line] 2009. doi:10.1007/s00134-009-1495-3.
  20. 20.
    Geeraerts T, Newcombe VFJ, Coles JP, Abate MJ, Perkes IE, Hutchinson PJA, et al. Use of T2-weighed magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. Crit Care. 2008;12:R114.CrossRefPubMedGoogle Scholar

Copyright information

© Humana Press Inc. 2009

Authors and Affiliations

  • Riccardo Moretti
    • 1
  • Barbara Pizzi
    • 1
  • Fabrizio Cassini
    • 1
  • Nicoletta Vivaldi
    • 1
  1. 1.Department of Anesthesia and Critical CareOspedale SS Antonio e Biagio e Cesare ArrigoAlessandriaItaly

Personalised recommendations