Clinical Neurology and Neurosurgery 204 (2021) 106609

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Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

Comparison of ultrasonography and computed tomography for measuring

optic nerve sheath diameter for the detection of elevated
intracranial pressure
Dae Yong Kim a, Sin Young Kim a, Dae Young Hong b, *, Bo Youn Sung c, Sung Lee d,
Jin Hui Paik e, Hyun Min Jung e
a
Department of Emergency Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
b
Department of Emergency Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
c
Department of Emergency Medicine, Taean Health Center & County Hospital, Taean, Republic of Korea
d
The Armed Forces Medical Command, Seongnam, Republic of Korea
e
Department of Emergency Medicine, Inha University School of Medicine, Incheon, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: The main aim of this study was to compare optic nerve sheath diameter (ONSD) measured using ul­
Intracranial pressure trasonography (USG) and computed tomography (CT) almost simultaneously in the same patients with suspected
Optic nerve elevated intracranial pressure. The other aim of this study was to evaluate the diagnostic ability for detecting
Ultrasonography
elevated intracranial pressure using ONSD measured by USG (USG-ONSD) and by CT (CT-ONSD).
Tomography
Patients and methods: This prospective, observational study was undertaken from June to October 2020 in the
emergency department (ED) of a tertiary medical center in Seoul. ONSD was measured by USG and CT at 3 mm
behind the posterior aspect of the globe.
Result: A total of 199 patients were enrolled. The median USG-ONSD and CT-ONSD were significantly higher in
patients with elevated intracranial pressure than in patients with normal intracranial pressure. The interclass
correlation coefficient between USG-ONSD and CT-ONSD was 0.785 (95% CI 0.715–0.837). A Bland–Altman plot
showed significant agreement between USG and CT measurements. The optimal cutoff for detecting elevated
intracranial pressure was >5.3 mm (sensitivity of 75.4% and specificity of 90.8%) for USG and >5.0 mm
(sensitivity of 68.4% and specificity of 85.2%) for CT.
Conclusion: The ONSD measured using USG and CT were increased in patients with elevated intracranial pres­
sure. Measurement of ONSD by USG and CT showed very high agreement.

1. Introduction
Elevated intracranial pressure (ICP) is a serious problem in critically
ill patients admitted to the emergency department (ED) or intensive care
unit. It is important to provide a prompt diagnosis and intervention
because elevated ICP can lead to poor neurological outcomes [1]. The
standard method for measuring ICP is direct measurement using intra­
parenchymal or intraventricular devices, whose use is associated with
complications such as infection and bleeding.
The optic nerve and its contents are continuous with the intracranial
subarachnoid space. Elevated ICP is transmitted to the optic nerve,
which expands in response, and the optic nerve sheath can expand
within a few seconds [2]. Prior publications have shown that measure­
ment of optic nerve sheath diameter (ONSD) using ultrasonography
(USG), computed tomography (CT), or magnetic resonance imaging
(MRI) is a reliable method for detecting elevated ICP [3–6]. Several
studies have compared ONSD measurements obtained using USG, CT,
and MRI [6–11]. However, these studies targeted only patients with
elevated ICP or normal ICP, and the time intervals between imaging
modalities were unclear or not short.
The main aim of this study was to compare measurements of ONSD
using USG (USG-ONSD) and CT (CT-ONS) obtained almost simulta­
neously in the same patients with suspected elevated ICP. The other aim
of this study was to evaluate the diagnostic ability for detecting elevated

* Corresponding author.
E-mail address: 20070123@kuh.ac.kr (D.Y. Hong).

https://doi.org/10.1016/j.clineuro.2021.106609
Received 3 January 2021; Received in revised form 18 February 2021; Accepted 17 March 2021
Available online 20 March 2021
0303-8467/© 2021 Elsevier B.V. All rights reserved.
D.Y. Kim et al. Clinical Neurology and Neurosurgery 204 (2021) 106609

ICP as measured by USG-ONSD and CT-ONSD.

2. Materials and methods

This prospective, observational study was undertaken from June to

October 2020 in the ED of a tertiary medical center in Seoul. The ethics
committee reviewed and approved the study protocol, and waived the
need for individual informed consent because of the noninterventional
nature.
The inclusion criteria were adult patients (age ≥19 years) suspected
of having elevated ICP. The exclusion criteria were ≤18 years of age; a
history of eye disease or significant ocular trauma, in which the imple­
mentation of USG may interfere with the diagnosis or treatment; or a
time interval of >30 min of time interval between USG and CT scanning.
The patients enrolled in this study were nonconsecutive because they
had visited the hospital when the two emergency physicians who per­
formed USG were on duty.
The sample size was calculated by assuming an expected reliability of
0.8, power of 90%, and α of 0.05. The sample size was estimated at 65
patients.
Fig. 2. Measurement of ONSD using computed tomography scan image.
2.1. ONSD measurements
2.2. Criteria for diagnosing increased intracranial pressure
USG measurements were performed in B-mode by two experienced
emergency physicians using an Affiniti 50 ultrasound machine (Philips, All CT images were reviewed and reported by an experienced
Amsterdam, Netherlands). The 4–12 MHz linear probe was applied neuroradiologist. The criteria for diagnosing elevated ICP on CT scan­
lightly on the closed upper eyelids of patients lying in the supine posi­ ning were one or more of the following: mass effect with midline shift
tion. ONSD was measured 3 mm behind the posterior aspect of the globe ≥3 mm, collapse of the third ventricle, hydrocephalus, effacement of
twice in each eye by the physician on duty (Fig. 1). The average of all sulci with obvious edema, or abnormal mesencephalic cisterns [5].
four measurements was calculated to yield a mean USG-ONSD.
All CT scans were conducted within 30 min after the USG examina­
tion. CT measurements were performed using an Optima CT660 64-slice 2.3. Statistical analysis
scanner (GE Healthcare, Chicago, IL, USA) with the patient lying in a
supine position. The image parameters of the CT scan were as follows: Statistical analyses were performed using IBM SPSS Statistics
slice thickness 5 mm, rotation time 0.5–1 s, tube voltage 120 kV, and (version 25; IBM, Armonk, NY, USA) and MedCalc (version 19.5.3;
tube current 200 mA. CT scanning was taken parallel to the infraorbi­ MedCalc Software, Ostend, Belgium). Categorical variables are pre­
tomeatal line. sented as counts and percentages, and the chi-square test was used for
CT-ONSD was performed independently by two experienced emer­ comparisons. Nonnormally distributed continuous variables including
gency physicians who were blinded to the clinical information and the age, ONSD, systolic blood pressure, diastolic blood pressure, pulse rate,
result of the USG-ONSD. The Centricity PACS Radiology RA1000 respiratory rate, body temperature, and Glasgow Coma Scale (GCS)
Workstation (GE Healthcare) was used for all measurements. ONSD was score are expressed as median (25–75% interquartile range). The Wil­
measured at 3 mm behind the globe twice in each eye using an elec­ coxon signed-rank test and the Mann–Whitney U test were used to
tronic caliper (Fig. 2). The average of all four measurements was compare between two groups. Agreement between the two image mo­
calculated to yield a mean CT-ONSD. dalities was analyzed using the intraclass correlation coefficient (ICC)
and the Bland–Altman plot.
The diagnostic performance between USG-ONSD and CT-ONSD for
detecting elevated ICP was evaluated by constructing receiver-operating
characteristic (ROC) curves, and the areas under the curve (AUCs) were
determined. The sensitivity, specificity, positive predictive value (PPV),
and negative predictive value (NPV) for identifying elevated ICP were
calculated and then compared between USG-ONSD and CT-ONSD. All
statistical analyses were two-sided, and p values <0.05 were considered
to be significant.

3. Results

Between June and October 2020, 199 patients with suspected

elevated ICP were enrolled in this study. The median age was 59 (46–75)
years and 87 (43.7%) patients were women. The median GCS score was
15 (IQR 14–15, range 3–15).
USG-ONSD and CT-ONSD measurements were performed in the left
and right eyes of all participants. USG-ONSD and CT-ONSD measure­
ments did not differ significantly between the left and right eyes
(p = 0.068 and p = 0.087, respectively).
Fig. 1. Measurement of optic nerve sheath diameter (ONSD) using Signs of elevated ICP in CT scans were observed in 57 patients
ultrasonography. (28.6%). The median USG-ONSD was significantly higher in the group

2
D.Y. Kim et al. Clinical Neurology and Neurosurgery 204 (2021) 106609

with elevated ICP in the group with normal ICP: 5.7 (5.2–5.9) mm vs 4.3 Table 2
(4.1–4.7) mm, respectively (p < 0.001) (Table 1). The median CT-ONSD Comparison of USG-ONSD and CT-ONSD according to ICP group.
was significantly higher in the elevated ICP group than in the normal ICP USG-ONSD (mm) CT-ONSD (mm) p value
group: 5.2 (4.7–5.6) mm vs 4.5 (4.2–4.8) mm, respectively.
Normal ICP (n = 142) 4.3 (4.1–4.7) 4.5 (4.2–4.8) 0.036
CT-ONSD was slightly higher than USG-ONSD in patients with Elevated ICP (n = 57) 5.7 (5.2–6.0) 5.2 (4.7–5.6) <0.001
normal ICP, but USG-ONSD was significantly higher than CT-ONSD in Total (n = 199) 4.6 (4.1–5.4) 4.6 (4.3–5.1) 0.214
patients with elevated ICP (Table 2). However, when all patients were
USG, ultrasonography; CT, computed tomography; ONSD, optic nerve sheath
considered together, USG-ONSD and CT-ONSD did not differ diameter; ICP, intracranial pressure. Data are presented as medina with inter­
significantly. quartile ranges.
The ICC between USG-ONSD and CT-ONSD was 0.785 (95% CI
0.715–0.837). The Bland–Altman plot indicated significant agreement
between USG and CT measurements (Fig. 3). The mean difference was
0.06 mm, and the 95% limits of agreement ranged between − 1.06 mm
and + 1.18 mm.
ROC curves were plotted to evaluate the diagnostic performance for
detecting elevated ICP for USG-ONSD and CT-ONSD (Fig. 4). The AUC of
USG-ONSD was 0.903 (95% CI 0.854–0.941, p < 0.001). The optimal
cutoff for USG-ONSD was >5.3 mm, with a sensitivity of 75.4%, speci­
ficity of 90.8%, PPV of 76.8%, and NPV of 90.2%. The AUC of CT-ONSD
was 0.784 (0.721–0.839, p < 0.001). The optimal cutoff for CT-ONSD
was >5.0 mm, with a sensitivity of 68.4%, specificity of 85.2%, PPV
of 65.0%, and NPV of 87.1%. The AUC was significantly higher for USG-
ONSD than for CT-ONSD (p = 0.002).

4. Discussion

ONSD measurement using USG is a simple, rapid, and noninvasive

method for detecting elevated ICP in ED patients [4,7,12]. ONSD
measured using CT and MRI has also been reported in the context of ICP
elevation [7,8,13]. Our results are consistent with those of previous
studies. The mean USG-ONSD and CT-ONSD were significantly higher in
patients with elevated ICP than in those without elevated ICP.
MRI is not easy to perform in most EDs and takes a long time. We
measured ONSD using CT and USG, and compared these measurements. Fig. 3. Bland–Altman plot showing the comparison of ONSD measured using
Few studies have directly compared measurements of ONSD obtained ultrasonography and computed tomography. The middle line indicates the
mean difference, and the dotted lines represent the 95% limits of agreement.
using USG and CT. Hassen et al. [12] reported a very high concordance
rate of <0.5 mm for ONSD measured using USG and CT. Bhandari et al.
[9] also found a strong correlation between ONSD measured using USG
and CT in patients with a ventriculoperitoneal shunt. In our study, the
ICC for ONSD measured using USG and CT was 0.785, which suggested
good reliability. By contrast, a recent study reported a significant dif­
ference between ONSD obtained using USG and CT in trauma patients
[7]. Those authors presumed that this difference was due to operation
dependency of USG despite adequate training. Two studies have re­
ported that ONSD measurement obtained using USG yielded acceptable
interobserver variability [14,15], but other studies have found greater
variation between physicians for USG-ONSD [16,17].

Table 1
Baseline characteristics of the enrolled patients.
Normal ICP Elevated ICP p value
(n = 142) (n = 57)

Age (years) 57 (44–73) 68 (51–78) <0.001

Female (n) 63 (44.4) 24 (42.1) 0.875
SBP (mmHg) 147 (128–167) 156 (134–174) 0.104
DBP (mmHg) 85 (77–98) 88 (76–101) 0.387
Pulse rate (/min) 86 (73–98) 78 (69–96) 0.085
Respiratory rate 20 (18–20) 20 (18–20) 0.804
(/min)
Body temperature (◦ C) 36.7 (36.4–37.0) 36.5 (36.0–36.9) 0.192
GCS score 15 (15–15) 12 (6–14) <0.001
USG-ONSD (mm) 4.3 (4.1–4.7) 5.7 (5.2–5.9) <0.001
CT-ONSD (mm) 4.5 (4.2–4.8) 5.2 (4.7–5.6) <0.001 Fig. 4. The receiver-operating characteristic curves for identifying elevated
ICP, intracranial pressure; SBP, systolic blood pressure; DBP, diastolic blood intracranial pressure for ONSD measured using ultrasonography and
pressure; GCS, Glasgow Coma Scale; USG, ultrasonography; ONSD, optic nerve computed tomography.
sheath diameter; CT, computed tomography. Data are presented as medina with
interquartile ranges or count (%).

3
D.Y. Kim et al.
Jeon et al. reported an optimal cutoff value of 5.6 mm for USG-ONSD
for detecting elevated ICP, with a sensitivity of 93.8% and specificity of
86.7% in Korean populations [18]. Similarly, our study found a cutoff
value of 5.3 mm for USG-ONSD for detecting elevated ICP, with a
sensitivity of 75.4% and specificity of 90.8%. Altayar et al. reported that
a cutoff value >5.5 mm for USG-ONSD predicted elevated ICP with a
sensitivity of 92.9% and specificity of 50% [19]. By contrast, Jenji­
tranant et al. reported a lower cutoff value of 3.15 mm for this method,
with a sensitivity of 97.4% and specificity of 13.8% [7]. Interestingly,
previous studies have reported a higher sensitivity than specificity for
detecting elevated ICP for USG-ONSD [7,18,19], whereas we found a
higher specificity than sensitivity for this method.
In our study, the cutoff value for detecting elevated ICP was 5.0 mm
for CT-ONSD, and the sensitivity and specificity were 68.4% and 85.2%,
respectively. Altayar et al. reported a higher cutoff value of >6.2 mm for
detecting elevated ICP for CT-ONSD, with a sensitivity of 64% and
specificity of 85% [19]. A recent study also reported a 4.8 mm cutoff
value for detecting increased ICP for CT-ONSD, with a sensitivity and
specificity of 60.5% and 61.2%, respectively [7]. In our study and other
studies, CT-ONSD had lower sensitivity than USG-ONSD for detecting
elevated ICP. In addition, Altayar et al. [18] and Jenjitranant et al. [7]
reported that the cutoff values for detecting elevated ICP were larger for
CT (6.2 mm and 4.8 mm, respectively) than for USG (5.5 mm and
3.15 mm, respectively). By contrast, the cutoff value was larger for USG
(5.3 mm) than for CT (5.0 mm) in our study. However, the optimal
cutoff values for USG-ONSD and CT-ONSD for detecting elevated ICP
have not been determined.
In our study, the AUC values for detecting elevated ICP were higher
for USG-ONSD than for CT-ONSD. The AUC value of USG ranged from
0.854 to 0.941, which indicates excellent discriminative power, and the
best cutoff value was 5.3 mm. Similarly, Geeraerts et al. [20] reported
an AUC value of 0.91 with a cutoff of 5.86 mm for USG-ONSD. Jeon et al.
[18] also reported AUC values of 0.844–0.983 for USG in Korean adults.
By contrast, Altayar et al. [19] found a higher AUC for CT (0.826) than
for USG (0.786) when screening for high ICP in patients with traumatic
brain injury. Sekhon et al. [21] reported an AUC of 0.83 for using CT to
predict increased ICP. These discrepancies may reflect differences in
various factors, such as the enrolled patients, modalities used for the two
radiology examinations, and inter-observer variations.
In our study, the B-mode of USG was used to measure ONSD. Mea­
surement by B-mode can be affected by the blooming effect [22,23],
which occurs because of the lack of standard sensitivity and is greater at
a lower sensitivity setting than a higher sensitivity setting. This effect is
<0.5 mm, which is not a problem for large lesions but may make a
difference when measuring ONSD. Various factors can influence the
difference between ONSD-USG and ONSD-CT, and we considered the
blooming effect as one possible factor. For this reason, measurement
using standardized A-mode can provide more precise results, but this
mode requires special skills and is more difficult to perform.
Enlargement of ONSD can be present in cases involving elevated ICP,
as well as optic neuritis, meningioma, or leukemic infiltration. The 30-
degree test is the best way to differentiate between these lesions [3,
24]. A decrease in ONSD of >5% from the initial position to 30-degree
eye gaze is considered as an indicator of fluid in the sheath and a
marker of elevated ICP.
Our study has several limitations. First, direct measurement of ICP is
an aggressive procedure in ED patients with a nonsevere condition, and
the criterion of elevated ICP was used as the basis for the CT findings.
Second, this study was conducted in a single urban hospital with a small
number of patients, and the results may not be generalizable to all pa­
tients suspected of having elevated ICP. Third, USG-ONSD was measured
by two physicians, and we cannot discount the possible effect of inter­
observer variation. Studies have reported a high degree of interobserver
reliability between the ONSD measured by USG [18,25].
In conclusion, the patients with elevated ICP had an increased ONSD
measured using USG and CT. We also found that ONSD measured using
4
Clinical Neurology and Neurosurgery 204 (2021) 106609
USG and CT almost simultaneously (within 30 min) showed very high
agreement.
Financial support
None.
CRediT authorship contribution statement
Dae Yong Kim: Investigation, Data curation, Formal analysis,
Writing - original draft. Sin Young Kim: Investigation, Formal analysis,
Writing - original draft. Dae Young Hong: Conceptualization, Investi­
gation, Formal analysis, Writing - original draft, Writing - review &
editing, Supervision. Bo Youn Sung: Resources, Investigation, Data
curation, Writing - review & editing. Sung Lee: Resources, Writing -
review & editing. Jin Hui Paik: Validation, Writing - review & editing.
Hyun Min Jung: Validation, Writing - review & editing.
Acknowledgments
None.
Declaration of competing interest
The authors report no declarations of interest.
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