Neurocritical Care

, Volume 21, Issue 2, pp 245–252 | Cite as

Association Between Optic Nerve Sheath Diameter and Mortality in Patients with Severe Traumatic Brain Injury

  • Mypinder S. SekhonEmail author
  • Paul McBeth
  • Jie Zou
  • Lu Qiao
  • Leif Kolmodin
  • William R. Henderson
  • Steve Reynolds
  • Donald E. G. Griesdale
Original Article



Increased intracranial pressure (ICP) is associated with worse outcomes following traumatic brain injury (TBI). Studies have confirmed that ICP is correlated with optic nerve sheath diameter (ONSD) on ultrasound. The aim of our study was to assess the independent relationship between ONSD measured using CT and mortality in a population of patients admitted with severe TBI.


We conducted a retrospective cohort study of patients with a TBI requiring ICP monitoring admitted to the ICU between April 2006 and May 2012 to two neurotrauma centers. ONSD was independently measured by two physicians blinded to patient outcomes. Multivariable logistic regression modeling was used to assess an association between ONSD and hospital mortality.


A total of 220 patients were included in the analysis. Overall, the cohort had a mean age of 35 (SD 17) years and 171 of 220 (79 %) were male. The median admission GCS was 6 (IQR 3–8). Intra-class correlation coefficient between raters for ONSD measurements was 0.92 (95 % CI 0.90–0.94, P < 0.0001). On multivariable analysis, each 1 mm increase in ONSD was associated with a twofold increase in hospital mortality (OR 2.0, 95 % CI 1.2–3.2, P = 0.007). Using linear regression, ONSD was independently associated with increased ICP in the first 48 h after admission (β = 4.4, 95 % CI 2.5–6.3, P < 0.0001).


In patients with TBI, ONSD measured on CT scanning was independently associated with ICP and mortality.


Optic nerve sheath diameter Computed tomography Traumatic brain injury Intracranial pressure Cerebral spinal fluid 



We would like to acknowledge the staff of the Vancouver General and Royal Columbian Hospitals for their support in the completion of this study. Dr. Griesdale is funded by the VGH & UBC Hospital Foundation Best of Health Fund.

Conflict of interest

None to declare.

Ethical Standards

All human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.


  1. 1.
    Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21:375–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Myburgh JA, et al. Epidemiology and 12-month outcomes from traumatic brain injury in Australia and New Zealand. J Trauma. 2008;64:854–62.PubMedCrossRefGoogle Scholar
  3. 3.
    Selassie AW, et al. Incidence of long-term disability following traumatic brain injury hospitalization, United States, 2003. J Head Trauma Rehabil. 2008;23:123–31.PubMedCrossRefGoogle Scholar
  4. 4.
    Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg. 2000;92:1–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Vik A, et al. Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg. 2008;109:678–84.PubMedCrossRefGoogle Scholar
  6. 6.
    Treggiari MM, Schutz N, Yanez ND, Romand J-A. Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review. Neurocrit Care. 2007;6:104–12.PubMedCrossRefGoogle Scholar
  7. 7.
    Roozenbeek B, Chiu YL, Lingsma HF, Gerber LM, Steyerberg EW, Ghajar J, Maas AI. Predicting 14 day mortality after severe traumatic brain injury: application of the IMPACT models in the brain trauma foundation TBI-trac New York database. J Neurotrauma. 2012;29(7):1306–12.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Balestreri M, et al. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care. 2006;4:8–13.PubMedCrossRefGoogle Scholar
  9. 9.
    Foundation BT, et al. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. J Neurotrauma. 2007;24(Suppl 1):S7–13.Google Scholar
  10. 10.
    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.PubMedCrossRefGoogle Scholar
  11. 11.
    Geeraerts T, et al. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Int Care Med. 2007;33:1704–11.CrossRefGoogle Scholar
  12. 12.
    Geeraerts T, Merceron S, Benhamou D, Vigué B, Duranteau J. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Int Care Med. 2008;34:2062–7.CrossRefGoogle Scholar
  13. 13.
    Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med. 2008;15:201–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Soldatos T, et al. Optic nerve sonography in the diagnostic evaluation of adult brain injury. Crit Care. 2008;12:R67.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Moretti R, Pizzi B, Cassini F, Vivaldi N. Reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial hemorrhage. Neurocrit Care. 2009;11:406–10.PubMedCrossRefGoogle Scholar
  16. 16.
    Potgieter DW, Kippin A, Ngu F, McKean C. Can accurate ultrasonographic measurement of the optic nerve sheath diameter (a non-invasive measure of intracranial pressure) be taught to novice operators in a single training session? Anaesth Intensive Care. 2011;39:95–100.PubMedCrossRefGoogle Scholar
  17. 17.
    Legrand A, et al. Estimation of optic nerve sheath diameter on an initial brain computed tomography scan can contribute prognostic information in traumatic brain injury patients. Crit Care. 2013;17:R61.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Vandenbroucke JP, et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. Epidemiology. 2007;18:805–35.PubMedCrossRefGoogle Scholar
  19. 19.
    Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery. 2005;57:1173–82.PubMedCrossRefGoogle Scholar
  20. 20.
    Roozenbeek B, et al. Prediction of outcome after moderate and severe traumatic brain injury: external validation of the international mission on prognosis and analysis of clinical trials (IMPACT) and corticoid randomisation after significant head injury (CRASH) prognostic mod. Crit Care Med. 2012;40:1609–17.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Chesnut RM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216–22.PubMedCrossRefGoogle Scholar
  22. 22.
    Geeraerts T, Launey Y, Martin L, Pottecher J, Vigué B, Duranteau J, Benhamou D. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med. 2007;33(10):1704–11.PubMedCrossRefGoogle Scholar
  23. 23.
    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;4(11):2062–7.CrossRefGoogle Scholar
  24. 24.
    Cammarata G, Ristagno G, Cammarata A, Mannanici G, Denaro C, Gullo A. Ocular ultrasound to detect intracranial hypertension in trauma patients. J Trauma. 2011;71:779–81.PubMedCrossRefGoogle Scholar
  25. 25.
    Ballantyne SA, O’Neill G, Hamilton R, Hollman AS. Observer variation in the sonographic measurement of optic nerve sheath diameter in normal adults. Eur J Ultrasound. 2002;15:145–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med. 2003;10:376–81.PubMedCrossRefGoogle Scholar
  27. 27.
    Tayal VS, Neulander M, Norton HJ, Foster T, Saunders T, Blaivas 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.PubMedCrossRefGoogle Scholar
  28. 28.
    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(3):R67.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Geeraerts T, Newcombe V, Coles J, Abate MG, Perkes IE, Hutchinson PJ, Outtrim JG, Chatfield DA, Menon DK. Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. Crit Care. 2008;12:114–20.CrossRefGoogle Scholar
  30. 30.
    Kimberly HH, Noble VE. Using MRI of the optic nerve sheath to detect elevated intracranial pressure. Crit Care. 2008;12:181.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL. Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocrit Care. 2011;15:506–15.PubMedCrossRefGoogle Scholar
  32. 32.
    Czosnyka M, Pickard J. Monitoring and interpretation of intracranial pressure. J Neurol Neurosurg Psychiatr. 2004;75:813–21.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Dubourg J, Javouhey E, Geeraerts T, Messerer M, Kassai B. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med. 2011;37(7):1059–68.PubMedCrossRefGoogle Scholar
  34. 34.
    Moretti R, Pizzi B. Ultrasonography of the optic nerve in neurocritically ill patients. Acta Anaesthesiol Scand. 2011;5(6):644–52.CrossRefGoogle Scholar
  35. 35.
    Launey Y, Nesseler N, Le Maguet P, Yannick M, Seguin P. Effect of osmotherapy on optic nerve sheath diameter in patients with increased intracranial pressure. J Neurotrauma. 2014;31:984–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Hansen HC, Helke 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.PubMedCrossRefGoogle Scholar
  37. 37.
    Helmke K, Hansen HC. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. Pediatr Radiol. 1996;26(10):701–5.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Mypinder S. Sekhon
    • 1
    Email author
  • Paul McBeth
    • 1
  • Jie Zou
    • 1
  • Lu Qiao
    • 1
  • Leif Kolmodin
    • 1
  • William R. Henderson
    • 1
  • Steve Reynolds
    • 2
  • Donald E. G. Griesdale
    • 1
    • 3
    • 4
  1. 1.Division of Critical Care Medicine, Department of Medicine, Vancouver General HospitalUniversity of British ColumbiaVancouverCanada
  2. 2.Department of Critical Care Medicine, Royal Columbian HospitalUniversity of British ColumbiaNew WestminsterCanada
  3. 3.Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General HospitalUniversity of British ColumbiaVancouverCanada
  4. 4.Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research InstituteUniversity of British ColumbiaVancouverCanada

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