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Intensive Care Med. 2018 Aug;44(8):1284-1294. doi: 10.1007/s00134-018-5305-7. Epub 2018 Jul 17.

Optic nerve sheath diameter measured sonographically as non-invasive estimator of intracranial pressure: a systematic review and meta-analysis.

Author information

Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy.
Neurosciences Critical Care Unit, Addenbrooke's Hospital, University of Cambridge, Box 1, Hills Road, CB2 0QQ, Cambridge, UK.
Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.
Department of Clinical Neurosciences, Division of Neurosurgery, Brain Physics Laboratory, Cambridge Biomedical Campus, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland.
Anaesthesia and Intensive Care Unit, E.O. Ospedali Galliera, Genoa, Italy.
Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
Paediatric Neurosurgery Unit, Division of Neurosurgery, Faculty of Health Sciences, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.
Department of Intensive Care, Clinique Universitaire de Bruxelles (CUB) Erasme, Brussels, Belgium.
School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.



Although invasive intracranial devices (IIDs) are the gold standard for intracranial pressure (ICP) measurement, ultrasonography of the optic nerve sheath diameter (ONSD) has been suggested as a potential non-invasive ICP estimator. We performed a meta-analysis to evaluate the diagnostic accuracy of sonographic ONSD measurement for assessment of intracranial hypertension (IH) in adult patients.


We searched on electronic databases (MEDLINE/PubMed®, Scopus®, Web of Science®, ScienceDirect®, Cochrane Library®) until 31 May 2018 for comparative studies that evaluated the efficacy of sonographic ONSD vs. ICP measurement with IID. Data were extracted independently by two authors. We used the QUADAS-2 tool for assessing the risk of bias (RB) of each study. A diagnostic meta-analysis following the bivariate approach and random-effects model was performed.


Seven prospective studies (320 patients) were evaluated for IH detection (assumed with ICP > 20 mmHg or > 25 cmH2O). The accuracy of included studies ranged from 0.811 (95% CI 0.678‒0.847) to 0.954 (95% CI 0.853‒0.983). Three studies were at high RB. No significant heterogeneity was found for the diagnostic odds ratio (DOR), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), with I2 < 50% for each parameter. The pooled DOR, PLR and NLR were 67.5 (95% CI 29‒135), 5.35 (95% CI 3.76‒7.53) and 0.088 (95% CI 0.046‒0.152), respectively. The area under the hierarchical summary receiver-operating characteristic curve (AUHSROC) was 0.938. In the subset of five studies (275 patients) with IH defined for ICP > 20 mmHg, the pooled DOR, PLR and NLR were 68.10 (95% CI 26.8‒144), 5.18 (95% CI 3.59‒7.37) and 0.087 (95% CI 0.041‒0.158), respectively, while the AUHSROC was 0.932.


Although the wide 95% CI in our pooled DOR suggests caution, ultrasonographic ONSD may be a potentially useful approach for assessing IH when IIDs are not indicated or available (CRD42018089137, PROSPERO).


Adult patients; Intracranial pressure; Invasive intracranial devices; Meta-analysis; Optic nerve sheath diameter; Ultrasonography

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