- Email: [email protected]
Real time optic nerve sheath diameter measurement during lumbar puncture
Accepted Manuscript Real time optic nerve sheath diameter measurement during lumbar puncture
Getaw Worku Hassen, Mohammed Al-Juboori, Barbara Koppel, Gokhan Akfirat, Hossein Kalantari PII: DOI: Reference:
S0735-6757(18)30038-X https://doi.org/10.1016/j.ajem.2018.01.037 YAJEM 57245
To appear in: Received date: Accepted date:
5 January 2018 10 January 2018
Please cite this article as: Getaw Worku Hassen, Mohammed Al-Juboori, Barbara Koppel, Gokhan Akfirat, Hossein Kalantari , Real time optic nerve sheath diameter measurement during lumbar puncture. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajem(2017), https://doi.org/ 10.1016/j.ajem.2018.01.037
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Real time optic nerve sheath diameter measurement during lumbar puncture Getaw Worku Hassen1, MD, PhD, Mohammed Al-Juboori2, MD, Barbara Koppel3, MD, Gokhan Akfirat3, MD, Hossein Kalantari1, MD, MPH 1
NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY NYMC, Metropolitan Hospital Center, Department of Medicine, New York, NY
T
2 3
US
CR
IP
NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, Division of Neurology, New York, NY
Corresponding author:
AN
Getaw Worku Hassen, MD, PhD
M
Professor of Emergency Medicine
ED
Director of Research
CE
1901 First Avenue
PT
NYMC, Metropolitan Hospital Center
New York, NY 10029
AC
Tel.: 2124236464
Email: [email protected]
Abstract:
ACCEPTED MANUSCRIPT Measurement of optic nerve sheath diameter (ONSD) using point of care ultrasound has been used to indirectly assess the intracranial pressure (ICP) particularly in conditions raise it such as trauma. Direct pressure measurements using probes reaching the ventricle system correlated with ONSD using ultrasound. Attempts were made to measure the ONSD pre and post lumbar
T
puncture (LP) after draining cerebrospinal fluid (CSF) as well as post ventricular shunt
IP
placement. We report ONSD measurement and dynamic changes during LP in a patient with
CR
known idiopathic intracranial hypertension (IIH).
US
Introduction:
Measurement of optic nerve sheath diameter (ONSD) has been used to indirectly asses the
AN
intracranial pressure (ICP) particularly is conditions that tend to raise the ICP such as trauma 1-8.
M
The measurements on point of care (POC) ultrasound (US) have been compared with
ED
measurements from Computed Tomography (CT) or Magnetic resonance imaging (MRI) as well direct pressure measurements using probes reaching the ventricle system. The results were
PT
comparable to the ICP reading using direct measurements 9-15. Attempts have been made to measure the ONSD pre and post lumbar puncture (LP) with removal of cerebrospinal fluid (CSF)
CE
as well as post ventricular shunt placement 16-19. Real time ONSD measurements in a few cases
AC
reported changes post procedure 20,21. These measurements were conducted at different time points after the LP. We report ONSD measurement and dynamic changes during LP in a patient with known idiopathic intracranial hypertension (IIH).
Case presentation:
ACCEPTED MANUSCRIPT A 66 year old woman with known IIH, diabetes mellitus (DM), hypertension and hyperlipidemia presented to the neurology clinic with mild diffuse headache, blurry vision and occasional floaters similar to her symptoms in the past that improved with CSF removal. Her neuroimaging from 2 years prior showed empty sella, a non-specific finding reported in IIH with normal
T
ventricles. She had had multiple LP, with CSF drainage in the past, but none for the past 2 years.
IP
She refused VP shut placement. She attributed the headaches to chronic sinusitis, but symptoms
CR
persisted despite treatment for sinusitis. She had been using the acetazolamide until about a year ago. Her headache and blurry vision progressed and she decided to come for the LP. She denied
US
weakness and numbness in the extremities, changes in speech, neck pain and rigidity.
AN
Physical examination revealed a patient in no acute distress. Visual acuity with corrective glasses
M
was 20/25 OD and 20/40 OS. Face was symmetric, no motor deficit and normal deep tendon
ED
reflexes. Funduscopic examination revealed bilaterally papilledema. After obtaining consent for the LP and to conduct POCUS. Tagaderm was applied to both closed
PT
eyes and using a linear probe of BK 3500 ultrasound system the ONSD was measured at a 3mm
CE
depth behind the globe in both transverse and sagittal planes. The average of three measurements was taken as the final ONSD. Before beginning the LP the POCUS showed bilateral prominent
AC
discs and widened ONSD, with a maximum measurement of 7.8mm (Figure 1A). The ultrasound probe was placed on the left eye to evaluate dynamic changes of the ONSD during the LP. The opening pressure was 54 cm H2O with clear CSF. As we withdraw the stylus and CSF start draining we noticed the dura mater started flickering and vibrating suggesting CSF movement out of the subarachnoid space. Gradually the size of the ONSD started to shrink (Figure 2 and supplement video 1). Due to patient’s movement and short duration of video clip recording time adjusted by default it was not possible to show the entire ONSD changes over 5-10 minutes
ACCEPTED MANUSCRIPT while draining CSF. After draining 36 cc of CSF the closing pressure was 25 cm H2O. After the procedure patient reported improvement of her symptoms and repeated neurological exam was unchanged. At the end of the procedure the ONSD measured 5.7 mm in the same eye (Figure 1B). No retinal detachment, no lens dislocation or vitreous hemorrhage was noted on either eye
IP
T
on the POCUS.
CR
Discussion:
Idiopathic intracranial hypertension is a condition that is associated with increased ICP without
US
mass or focal neurological deficit. Patients usually complain of headache, nausea and blurry vision to varying degrees. A CT scan of the head may show empty sella and slit-like ventricles.
AN
Treatment options include medical management with acetazolamide and intermittent LP with
M
CSF drainage. Surgical options include lumbar or ventricular peritoneal shunts and optic nerve
ED
sheath fenestration 22-29. Patients with IHH could receive repeated CT scans depending on their symptomatology and/or if they change physician or institution frequently. The measurement of
PT
ONSD is optimal for these patients to avoid repeated radiation exposure without compromising their care. For instance in another patient ONSD measurement was used to differentiate the pain
CE
from low pressure syndrome from post LP vs. pain from increased ICP in a follow up visit 16.
AC
Past studies and case reports have shown changes in ONSD after 30 min of CSF drainage and 16 hours after placement of ventricuoperitoneal shunt in a child with obstructive hydrocephalus from a tumor 19,20. We believe our case represents the first continuous real time ONSD dynamic change measurement during an LP. We had some technical challenges including shorter recording time and patient’s eye movement. Adjusting the ultrasound machine for longer recording time could capture all changes without interruption. Conclusion:
ACCEPTED MANUSCRIPT Measurement of ONSD is a valuable non-invasive method to evaluate ICP especially during CSF drainage and as a follow up tool. It may be a better surrogate marker than static images of the brain for changes in the ICP as its measurements reflect the actual pressure changes compared to CT scan findings which may not change quickly with acute pressure changes. Large multi-center
IP
T
studies involving children and adults are required to validate this hypothesis.
6
7
8 9
10 11 12
13 14
US
AN
M
5
ED
4
PT
3
CE
2
Blaivas, M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med 7, 947-950 (2000). Blaivas, M., Theodoro, D. & Sierzenski, P. R. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med 10, 376-381 (2003). Tayal, V. S. et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 49, 508-514 (2007). Tsung, J. W., Blaivas, M., Cooper, A. & Levick, N. R. A rapid noninvasive method of detecting elevated intracranial pressure using bedside ocular ultrasound: application to 3 cases of head trauma in the pediatric emergency department. Pediatric emergency care 21, 94-98 (2005). Cammarata, G. et al. Ocular ultrasound to detect intracranial hypertension in trauma patients. J Trauma 71, 779-781. Helmke, K. & Hansen, H. C. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. I. Experimental study. Pediatr Radiol 26, 701705 (1996). Helmke, K. & Hansen, H. C. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension II. Patient study. Pediatr Radiol 26, 706-710 (1996). Liu, D. et al. Assessment of intracranial pressure with ultrasonographic retrobulbar optic nerve sheath diameter measurement. BMC Neurol 17, 188, doi:10.1186/s12883-017-0964-5 (2017). Hassen, G. W. et al. Accuracy of optic nerve sheath diameter measurement by emergency physicians using bedside ultrasound. J Emerg Med 48, 450-457, doi:10.1016/j.jemermed.2014.09.060 (2015). Kimberly, H. H. & Noble, V. E. Using MRI of the optic nerve sheath to detect elevated intracranial pressure. Crit Care 12, 181 (2008). Kimberly, H. H., Shah, S., Marill, K. & Noble, V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 15, 201-204 (2008). Geeraerts, T., Merceron, S., Benhamou, D., Vigue, B. & Duranteau, J. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 34, 2062-2067 (2008). Geeraerts, T. et al. Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. Crit Care 12, R114 (2008). Ohle, R., McIsaac, S. M., Woo, M. Y. & Perry, J. J. Sonography of the Optic Nerve Sheath Diameter for Detection of Raised Intracranial Pressure Compared to Computed Tomography: A
AC
1
CR
References:
ACCEPTED MANUSCRIPT
15
16
23 24 25 26
27
28
29
CR
US
AN
M
22
ED
21
PT
20
CE
19
AC
18
IP
T
17
Systematic Review and Meta-analysis. J Ultrasound Med 34, 1285-1294, doi:10.7863/ultra.34.7.1285 (2015). Kalantari, H. et al. Correlation of optic nerve sheath diameter measurements by computed tomography and magnetic resonance imaging. Am J Emerg Med 31, 1595-1597, doi:10.1016/j.ajem.2013.07.028 (2013). Hassen, G. W., Nazeer, O., Manizate, F., Patel, N. & Kalantari, H. The role of bedside ultrasound in pretherapeutic and posttherapeutic lumbar puncture in patient with idiopathic intracranial hypertension. Am J Emerg Med 32, 1298 e1293-1294, doi:10.1016/j.ajem.2014.03.028 (2014). del Saz-Saucedo, P. et al. Sonographic assessment of the optic nerve sheath diameter in the diagnosis of idiopathic intracranial hypertension. J Neurol Sci 361, 122-127, doi:10.1016/j.jns.2015.12.032 (2016). Caffery, T. S., Perret, J. N., Musso, M. W. & Jones, G. N. Optic nerve sheath diameter and lumbar puncture opening pressure in nontrauma patients suspected of elevated intracranial pressure. Am J Emerg Med 32, 1513-1515, doi:10.1016/j.ajem.2014.09.014 (2014). Ayalew Zewdie, H. T., Abenezer Tirsit Aklilu, Tsegazeab Laeke Teklemariam, Yordanos Ashagre, Yemsrach Bizuneh, Aklilu Azazh, Getaw Worku Hassen. Bedside ultrasound as a simple noninvasive method of assessing intracranial pressure in a limited resource setting. African Journal of Emergency Medicine Volume 6, Issue 3, (September 2016, Pages e1-e4). Singleton, J., Dagan, A., Edlow, J. A. & Hoffmann, B. Real-time optic nerve sheath diameter reduction measured with bedside ultrasound after therapeutic lumbar puncture in a patient with idiopathic intracranial hypertension. Am J Emerg Med 33, 860 e865-867, doi:10.1016/j.ajem.2014.12.030 (2015). Hassani, S. N. & Bard, R. L. Real time ophthalmic ultrasonography. Radiology 127, 213-219 (1978). Baykan, B., Ekizoglu, E. & Altiokka Uzun, G. An update on the pathophysiology of idiopathic intracranial hypertension alias pseudotumor cerebri. Agri 27, 63-72, doi:10.5505/agri.2015.22599 (2015). Friedman, D. I. The pseudotumor cerebri syndrome. Neurol Clin 32, 363-396, doi:10.1016/j.ncl.2014.01.001 (2014). McGeeney, B. E. & Friedman, D. I. Pseudotumor cerebri pathophysiology. Headache 54, 445458, doi:10.1111/head.12291 (2014). Galgano, M. A. & Deshaies, E. M. An update on the management of pseudotumor cerebri. Clin Neurol Neurosurg 115, 252-259, doi:10.1016/j.clineuro.2012.11.018 (2013). Yaqub, M. A., Mehboob, M. A. & Islam, Q. U. Efficacy and safety of optic nerve sheath fenestration in patients with raised intracranial pressure. Pak J Med Sci 33, 471-475, doi:10.12669/pjms.332.11937 (2017). Zagardo, M. T., Cail, W. S., Kelman, S. E. & Rothman, M. I. Reversible empty sella in idiopathic intracranial hypertension: an indicator of successful therapy? AJNR Am J Neuroradiol 17, 19531956 (1996). Menger, R. P. et al. A comparison of lumboperitoneal and ventriculoperitoneal shunting for idiopathic intracranial hypertension: an analysis of economic impact and complications using the Nationwide Inpatient Sample. Neurosurg Focus 37, E4, doi:10.3171/2014.8.FOCUS14436 (2014). McGirt, M. J. et al. Cerebrospinal fluid shunt placement for pseudotumor cerebri-associated intractable headache: predictors of treatment response and an analysis of long-term outcomes. J Neurosurg 101, 627-632, doi:10.3171/jns.2004.101.4.0627 (2004).
ACCEPTED MANUSCRIPT Figure 1 Optic nerve sheath diameter measurements A. Optic nerve sheath diameter before the LP B. Optic nerve sheath diameter at the end of the procedure
T
Figure 2 and supplement video 1
IP
Figure 2 a picture representing the optic nerve and associated structures
CR
Red arrow pointing at the dura mater
US
White arrow pointing at the optic disc
AN
The space between the green arrows represent the subarachnoid space
M
The space between the yellow arrows represent the optic nerve Dynamic changes of the ONSD during LP. After removing the stylet and CSF starts draining the
ED
dura mater started flickering and vibrating suggesting CSF movement out of the subarachnoid
AC
CE
PT
space. Gradually the size of the ONSD started to shrink.
Figure 1
Figure 2
Getaw Worku Hassen, Mohammed Al-Juboori, Barbara Koppel, Gokhan Akfirat, Hossein Kalantari PII: DOI: Reference:
S0735-6757(18)30038-X https://doi.org/10.1016/j.ajem.2018.01.037 YAJEM 57245
To appear in: Received date: Accepted date:
5 January 2018 10 January 2018
Please cite this article as: Getaw Worku Hassen, Mohammed Al-Juboori, Barbara Koppel, Gokhan Akfirat, Hossein Kalantari , Real time optic nerve sheath diameter measurement during lumbar puncture. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajem(2017), https://doi.org/ 10.1016/j.ajem.2018.01.037
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Real time optic nerve sheath diameter measurement during lumbar puncture Getaw Worku Hassen1, MD, PhD, Mohammed Al-Juboori2, MD, Barbara Koppel3, MD, Gokhan Akfirat3, MD, Hossein Kalantari1, MD, MPH 1
NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY NYMC, Metropolitan Hospital Center, Department of Medicine, New York, NY
T
2 3
US
CR
IP
NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, Division of Neurology, New York, NY
Corresponding author:
AN
Getaw Worku Hassen, MD, PhD
M
Professor of Emergency Medicine
ED
Director of Research
CE
1901 First Avenue
PT
NYMC, Metropolitan Hospital Center
New York, NY 10029
AC
Tel.: 2124236464
Email: [email protected]
Abstract:
ACCEPTED MANUSCRIPT Measurement of optic nerve sheath diameter (ONSD) using point of care ultrasound has been used to indirectly assess the intracranial pressure (ICP) particularly in conditions raise it such as trauma. Direct pressure measurements using probes reaching the ventricle system correlated with ONSD using ultrasound. Attempts were made to measure the ONSD pre and post lumbar
T
puncture (LP) after draining cerebrospinal fluid (CSF) as well as post ventricular shunt
IP
placement. We report ONSD measurement and dynamic changes during LP in a patient with
CR
known idiopathic intracranial hypertension (IIH).
US
Introduction:
Measurement of optic nerve sheath diameter (ONSD) has been used to indirectly asses the
AN
intracranial pressure (ICP) particularly is conditions that tend to raise the ICP such as trauma 1-8.
M
The measurements on point of care (POC) ultrasound (US) have been compared with
ED
measurements from Computed Tomography (CT) or Magnetic resonance imaging (MRI) as well direct pressure measurements using probes reaching the ventricle system. The results were
PT
comparable to the ICP reading using direct measurements 9-15. Attempts have been made to measure the ONSD pre and post lumbar puncture (LP) with removal of cerebrospinal fluid (CSF)
CE
as well as post ventricular shunt placement 16-19. Real time ONSD measurements in a few cases
AC
reported changes post procedure 20,21. These measurements were conducted at different time points after the LP. We report ONSD measurement and dynamic changes during LP in a patient with known idiopathic intracranial hypertension (IIH).
Case presentation:
ACCEPTED MANUSCRIPT A 66 year old woman with known IIH, diabetes mellitus (DM), hypertension and hyperlipidemia presented to the neurology clinic with mild diffuse headache, blurry vision and occasional floaters similar to her symptoms in the past that improved with CSF removal. Her neuroimaging from 2 years prior showed empty sella, a non-specific finding reported in IIH with normal
T
ventricles. She had had multiple LP, with CSF drainage in the past, but none for the past 2 years.
IP
She refused VP shut placement. She attributed the headaches to chronic sinusitis, but symptoms
CR
persisted despite treatment for sinusitis. She had been using the acetazolamide until about a year ago. Her headache and blurry vision progressed and she decided to come for the LP. She denied
US
weakness and numbness in the extremities, changes in speech, neck pain and rigidity.
AN
Physical examination revealed a patient in no acute distress. Visual acuity with corrective glasses
M
was 20/25 OD and 20/40 OS. Face was symmetric, no motor deficit and normal deep tendon
ED
reflexes. Funduscopic examination revealed bilaterally papilledema. After obtaining consent for the LP and to conduct POCUS. Tagaderm was applied to both closed
PT
eyes and using a linear probe of BK 3500 ultrasound system the ONSD was measured at a 3mm
CE
depth behind the globe in both transverse and sagittal planes. The average of three measurements was taken as the final ONSD. Before beginning the LP the POCUS showed bilateral prominent
AC
discs and widened ONSD, with a maximum measurement of 7.8mm (Figure 1A). The ultrasound probe was placed on the left eye to evaluate dynamic changes of the ONSD during the LP. The opening pressure was 54 cm H2O with clear CSF. As we withdraw the stylus and CSF start draining we noticed the dura mater started flickering and vibrating suggesting CSF movement out of the subarachnoid space. Gradually the size of the ONSD started to shrink (Figure 2 and supplement video 1). Due to patient’s movement and short duration of video clip recording time adjusted by default it was not possible to show the entire ONSD changes over 5-10 minutes
ACCEPTED MANUSCRIPT while draining CSF. After draining 36 cc of CSF the closing pressure was 25 cm H2O. After the procedure patient reported improvement of her symptoms and repeated neurological exam was unchanged. At the end of the procedure the ONSD measured 5.7 mm in the same eye (Figure 1B). No retinal detachment, no lens dislocation or vitreous hemorrhage was noted on either eye
IP
T
on the POCUS.
CR
Discussion:
Idiopathic intracranial hypertension is a condition that is associated with increased ICP without
US
mass or focal neurological deficit. Patients usually complain of headache, nausea and blurry vision to varying degrees. A CT scan of the head may show empty sella and slit-like ventricles.
AN
Treatment options include medical management with acetazolamide and intermittent LP with
M
CSF drainage. Surgical options include lumbar or ventricular peritoneal shunts and optic nerve
ED
sheath fenestration 22-29. Patients with IHH could receive repeated CT scans depending on their symptomatology and/or if they change physician or institution frequently. The measurement of
PT
ONSD is optimal for these patients to avoid repeated radiation exposure without compromising their care. For instance in another patient ONSD measurement was used to differentiate the pain
CE
from low pressure syndrome from post LP vs. pain from increased ICP in a follow up visit 16.
AC
Past studies and case reports have shown changes in ONSD after 30 min of CSF drainage and 16 hours after placement of ventricuoperitoneal shunt in a child with obstructive hydrocephalus from a tumor 19,20. We believe our case represents the first continuous real time ONSD dynamic change measurement during an LP. We had some technical challenges including shorter recording time and patient’s eye movement. Adjusting the ultrasound machine for longer recording time could capture all changes without interruption. Conclusion:
ACCEPTED MANUSCRIPT Measurement of ONSD is a valuable non-invasive method to evaluate ICP especially during CSF drainage and as a follow up tool. It may be a better surrogate marker than static images of the brain for changes in the ICP as its measurements reflect the actual pressure changes compared to CT scan findings which may not change quickly with acute pressure changes. Large multi-center
IP
T
studies involving children and adults are required to validate this hypothesis.
6
7
8 9
10 11 12
13 14
US
AN
M
5
ED
4
PT
3
CE
2
Blaivas, M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med 7, 947-950 (2000). Blaivas, M., Theodoro, D. & Sierzenski, P. R. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med 10, 376-381 (2003). Tayal, V. S. et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 49, 508-514 (2007). Tsung, J. W., Blaivas, M., Cooper, A. & Levick, N. R. A rapid noninvasive method of detecting elevated intracranial pressure using bedside ocular ultrasound: application to 3 cases of head trauma in the pediatric emergency department. Pediatric emergency care 21, 94-98 (2005). Cammarata, G. et al. Ocular ultrasound to detect intracranial hypertension in trauma patients. J Trauma 71, 779-781. Helmke, K. & Hansen, H. C. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. I. Experimental study. Pediatr Radiol 26, 701705 (1996). Helmke, K. & Hansen, H. C. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension II. Patient study. Pediatr Radiol 26, 706-710 (1996). Liu, D. et al. Assessment of intracranial pressure with ultrasonographic retrobulbar optic nerve sheath diameter measurement. BMC Neurol 17, 188, doi:10.1186/s12883-017-0964-5 (2017). Hassen, G. W. et al. Accuracy of optic nerve sheath diameter measurement by emergency physicians using bedside ultrasound. J Emerg Med 48, 450-457, doi:10.1016/j.jemermed.2014.09.060 (2015). Kimberly, H. H. & Noble, V. E. Using MRI of the optic nerve sheath to detect elevated intracranial pressure. Crit Care 12, 181 (2008). Kimberly, H. H., Shah, S., Marill, K. & Noble, V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 15, 201-204 (2008). Geeraerts, T., Merceron, S., Benhamou, D., Vigue, B. & Duranteau, J. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 34, 2062-2067 (2008). Geeraerts, T. et al. Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. Crit Care 12, R114 (2008). Ohle, R., McIsaac, S. M., Woo, M. Y. & Perry, J. J. Sonography of the Optic Nerve Sheath Diameter for Detection of Raised Intracranial Pressure Compared to Computed Tomography: A
AC
1
CR
References:
ACCEPTED MANUSCRIPT
15
16
23 24 25 26
27
28
29
CR
US
AN
M
22
ED
21
PT
20
CE
19
AC
18
IP
T
17
Systematic Review and Meta-analysis. J Ultrasound Med 34, 1285-1294, doi:10.7863/ultra.34.7.1285 (2015). Kalantari, H. et al. Correlation of optic nerve sheath diameter measurements by computed tomography and magnetic resonance imaging. Am J Emerg Med 31, 1595-1597, doi:10.1016/j.ajem.2013.07.028 (2013). Hassen, G. W., Nazeer, O., Manizate, F., Patel, N. & Kalantari, H. The role of bedside ultrasound in pretherapeutic and posttherapeutic lumbar puncture in patient with idiopathic intracranial hypertension. Am J Emerg Med 32, 1298 e1293-1294, doi:10.1016/j.ajem.2014.03.028 (2014). del Saz-Saucedo, P. et al. Sonographic assessment of the optic nerve sheath diameter in the diagnosis of idiopathic intracranial hypertension. J Neurol Sci 361, 122-127, doi:10.1016/j.jns.2015.12.032 (2016). Caffery, T. S., Perret, J. N., Musso, M. W. & Jones, G. N. Optic nerve sheath diameter and lumbar puncture opening pressure in nontrauma patients suspected of elevated intracranial pressure. Am J Emerg Med 32, 1513-1515, doi:10.1016/j.ajem.2014.09.014 (2014). Ayalew Zewdie, H. T., Abenezer Tirsit Aklilu, Tsegazeab Laeke Teklemariam, Yordanos Ashagre, Yemsrach Bizuneh, Aklilu Azazh, Getaw Worku Hassen. Bedside ultrasound as a simple noninvasive method of assessing intracranial pressure in a limited resource setting. African Journal of Emergency Medicine Volume 6, Issue 3, (September 2016, Pages e1-e4). Singleton, J., Dagan, A., Edlow, J. A. & Hoffmann, B. Real-time optic nerve sheath diameter reduction measured with bedside ultrasound after therapeutic lumbar puncture in a patient with idiopathic intracranial hypertension. Am J Emerg Med 33, 860 e865-867, doi:10.1016/j.ajem.2014.12.030 (2015). Hassani, S. N. & Bard, R. L. Real time ophthalmic ultrasonography. Radiology 127, 213-219 (1978). Baykan, B., Ekizoglu, E. & Altiokka Uzun, G. An update on the pathophysiology of idiopathic intracranial hypertension alias pseudotumor cerebri. Agri 27, 63-72, doi:10.5505/agri.2015.22599 (2015). Friedman, D. I. The pseudotumor cerebri syndrome. Neurol Clin 32, 363-396, doi:10.1016/j.ncl.2014.01.001 (2014). McGeeney, B. E. & Friedman, D. I. Pseudotumor cerebri pathophysiology. Headache 54, 445458, doi:10.1111/head.12291 (2014). Galgano, M. A. & Deshaies, E. M. An update on the management of pseudotumor cerebri. Clin Neurol Neurosurg 115, 252-259, doi:10.1016/j.clineuro.2012.11.018 (2013). Yaqub, M. A., Mehboob, M. A. & Islam, Q. U. Efficacy and safety of optic nerve sheath fenestration in patients with raised intracranial pressure. Pak J Med Sci 33, 471-475, doi:10.12669/pjms.332.11937 (2017). Zagardo, M. T., Cail, W. S., Kelman, S. E. & Rothman, M. I. Reversible empty sella in idiopathic intracranial hypertension: an indicator of successful therapy? AJNR Am J Neuroradiol 17, 19531956 (1996). Menger, R. P. et al. A comparison of lumboperitoneal and ventriculoperitoneal shunting for idiopathic intracranial hypertension: an analysis of economic impact and complications using the Nationwide Inpatient Sample. Neurosurg Focus 37, E4, doi:10.3171/2014.8.FOCUS14436 (2014). McGirt, M. J. et al. Cerebrospinal fluid shunt placement for pseudotumor cerebri-associated intractable headache: predictors of treatment response and an analysis of long-term outcomes. J Neurosurg 101, 627-632, doi:10.3171/jns.2004.101.4.0627 (2004).
ACCEPTED MANUSCRIPT Figure 1 Optic nerve sheath diameter measurements A. Optic nerve sheath diameter before the LP B. Optic nerve sheath diameter at the end of the procedure
T
Figure 2 and supplement video 1
IP
Figure 2 a picture representing the optic nerve and associated structures
CR
Red arrow pointing at the dura mater
US
White arrow pointing at the optic disc
AN
The space between the green arrows represent the subarachnoid space
M
The space between the yellow arrows represent the optic nerve Dynamic changes of the ONSD during LP. After removing the stylet and CSF starts draining the
ED
dura mater started flickering and vibrating suggesting CSF movement out of the subarachnoid
AC
CE
PT
space. Gradually the size of the ONSD started to shrink.
Figure 1
Figure 2