Validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests

View More View Less
  • 1 Neuro-intensive Care Unit, Departments of Neurology and Pediatric Radiology, University Hospital Eppendorf, Hamburg, Germany
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

✓ Raised intracranial pressure leads to increased pressure around the optic nerve (ON), which underlies the formation of papilledema and the enlargement of the dural optic nerve sheath (ONS). In clinical practice, the presence of widened ONSs is demonstrable on neuroimaging, but their relationship to cerebrospinal fluid (CSF) pressure remains unknown. The authors investigated the ONS response to pressure during CSF absorption studies in 12 patients undergoing neurological testing. The ONS diameter was evaluated by serial B-mode ultrasound scans of the anterior ON near its entry into the globe.

All patients tested showed ONS diameter changes that exhibited covariance with the alteration of lumbar CSF pressure and were completely reversible during the infusion tests. The maximum difference in ONS diameter between baseline and peak pressure conditions was 1.8 mm on average (range 0.7–3.1 mm), corresponding to an average ONS diameter variation of 45% (range 15–89%). Regression analysis yielded a linear covariance between ONS diameter and CSF pressure with different slopes across subjects (0.019–0.071 mm/mm Hg, mean r = 0.78). However, this linear relationship was only present within a CSF pressure interval. This interval differed between patients: ONS dilation commenced at pressure thresholds between 15 mm Hg and 30 mm Hg and in some patients saturation of the response (constant ONS diameter) occurred between 30 mm Hg and 40 mm Hg. With a single exception, definitely enlarged ONS diameters (> 5 mm) were present when CSF pressure exceeded levels of 30 mm Hg. Retrospectively, discrimination between normal and elevated outflow resistance was possible on the basis of the ONS response to intrathecal infusion alone.

It is concluded that the human ONS has sufficient elasticity to allow a detectable dilation in response to intracranial hypertension. Because of a variable pressure—diameter relationship, the subarachnoid pressure cannot be predicted exactly by single scans. Therefore, the clinical relevance of this method relies on the demonstration of pathologically enlarged sheaths or ongoing enlargement on serial ultrasonography studies.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address reprint requests to: Hans-Christian Hansen, M.D., Neurology Department, Neuro-intensive Care Unit, University Hospital Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.
  • 1.

    Aulhorn E: Ophthalmological features of pseudo-tumor cerebri. Report of 18 cases. Doc Ophthalmol 58:2533, 1984 Aulhorn E: Ophthalmological features of pseudo-tumor cerebri. Report of 18 cases. Doc Ophthalmol 58:25–33, 1984

    • Search Google Scholar
    • Export Citation
  • 2.

    Brinker T, , Bötel C, & Rotkötter HJ, et al: The perineural pathway of cerebrospinal fluid absorption into the cervical lymphatic system. Morphological findings in rats, cats, dogs and monkeys, in Nagai H, , Kamiya K, & Ishii S (eds): Intracranial Pressure IX. New York: Springer-Verlag, 1994, pp 132135 Brinker T, Bötel C, Rotkötter HJ, et al: The perineural pathway of cerebrospinal fluid absorption into the cervical lymphatic system. Morphological findings in rats, cats, dogs and monkeys, in Nagai H, Kamiya K, Ishii S (eds): Intracranial Pressure IX. New York: Springer-Verlag, 1994, pp 132–135

    • Search Google Scholar
    • Export Citation
  • 3.

    Cennamo G, , Gangemi M, & Stella L: The comparison between endocranial pressure and optic nerve diameter: an ultrasonographic study. Doc Ophthalmol Proc Ser 48:603606, 1987 Cennamo G, Gangemi M, Stella L: The comparison between endocranial pressure and optic nerve diameter: an ultrasonographic study. Doc Ophthalmol Proc Ser 48:603–606, 1987

    • Search Google Scholar
    • Export Citation
  • 4.

    Czosnyka M, , Gjerris, & Maksymovic W, et al: Computerised lumbar infusion test-multicentre experience in clinical studies in hydrocephalus, in Nagai H, , Kamiya K, & Ishii S (eds): Intracranial Pressure IX. New York: Springer-Verlag, 1994, pp 494495 Czosnyka M, Gjerris, Maksymovic W, et al: Computerised lumbar infusion test-multicentre experience in clinical studies in hydrocephalus, in Nagai H, Kamiya K, Ishii S (eds): Intracranial Pressure IX. New York: Springer-Verlag, 1994, pp 494–495

    • Search Google Scholar
    • Export Citation
  • 5.

    Erlich SS, , McComb JG, & Hyman S, et al: Ultrastructure of the orbital pathway for cerebrospinal fluid drainage in rabbits. Neurosurg 70:926931, 1989 Erlich SS, McComb JG, Hyman S, et al: Ultrastructure of the orbital pathway for cerebrospinal fluid drainage in rabbits. Neurosurg 70:926–931, 1989

    • Search Google Scholar
    • Export Citation
  • 6.

    Ernest JT, & Potts AM: Pathophysiology of the distal portion of the optic nerve. I. Tissue pressure relationships. Am J Ophthalmol 66:373380, 1968 Ernest JT, Potts AM: Pathophysiology of the distal portion of the optic nerve. I. Tissue pressure relationships. Am J Ophthalmol 66:373–380, 1968

    • Search Google Scholar
    • Export Citation
  • 7.

    Fishman RA: Cerebrospinal Fluid in Diseases of the Nervous System, ed 2. Philadelphia: WB Saunders, 1992 Fishman RA: Cerebrospinal Fluid in Diseases of the Nervous System, ed 2. Philadelphia: WB Saunders, 1992

    • Search Google Scholar
    • Export Citation
  • 8.

    Galetta S, , Byrne SF, & Smith JL: Echographic correlation of optic nerve sheath size and cerebrospinal fluid pressure. J Clin Neuroophthalmol 9:7982, 1989 Galetta S, Byrne SF, Smith JL: Echographic correlation of optic nerve sheath size and cerebrospinal fluid pressure. J Clin Neuroophthalmol 9:79–82, 1989

    • Search Google Scholar
    • Export Citation
  • 9.

    Gangemi M, , Cennamo G, & Maiuri F, et al: Echographic measurement of the optic nerve in patients with intracranial hypertension. Neurochirurgia 30:5355, 1987 Gangemi M, Cennamo G, Maiuri F, et al: Echographic measurement of the optic nerve in patients with intracranial hypertension. Neurochirurgia 30:53–55, 1987

    • Search Google Scholar
    • Export Citation
  • 10.

    Gass A, , Barker GJ, & Mosely IF, et al: High-resolution MRI of optic neuropathies. Neurology 44 (Suppl 2):A267, 1994 (Abstract) Gass A, Barker GJ, Mosely IF, et al: High-resolution MRI of optic neuropathies. Neurology 44 (Suppl 2):A267, 1994 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 11.

    Gjerris F, , Soelberg Sørensen P, & Vorstrup S, et al: Intracranial pressure, conductance to cerebrospinal outflow, and cerebral blood flow in patients with benign intracranial hypertension (pseudotumor cerebri). Ann Neurol 17:158162, 1985 Gjerris F, Soelberg Sørensen P, Vorstrup S, et al: Intracranial pressure, conductance to cerebrospinal outflow, and cerebral blood flow in patients with benign intracranial hypertension (pseudotumor cerebri). Ann Neurol 17:158–162, 1985

    • Search Google Scholar
    • Export Citation
  • 12.

    Guthoff R: Ultrasound in Ophthalmologic Diagnosis. A Practical Guide. New York: Thieme, 1991 Guthoff R: Ultrasound in Ophthalmologic Diagnosis. A Practical Guide. New York: Thieme, 1991

    • Search Google Scholar
    • Export Citation
  • 13.

    Guthoff R, , Triebel G, & Schroeder W, et al: Evaluation of the subarachnoidal space—comparisons between ultrasound and high resolution NMR-techniques. Doc Ophthalmol Proc Ser 53:5562, 1990 Guthoff R, Triebel G, Schroeder W, et al: Evaluation of the subarachnoidal space—comparisons between ultrasound and high resolution NMR-techniques. Doc Ophthalmol Proc Ser 53:55–62, 1990

    • Search Google Scholar
    • Export Citation
  • 14.

    Hansen HC, & Helmke K: The subarachnoid space surrounding the optic nerves. An ultrasound study of the optic nerve sheath. Surg Radiol Anat 18:16, 1996 Hansen HC, Helmke K: The subarachnoid space surrounding the optic nerves. An ultrasound study of the optic nerve sheath. Surg Radiol Anat 18:1–6, 1996

    • Search Google Scholar
    • Export Citation
  • 15.

    Hansen HC, , Helmke K, & Kunze K: Optic nerve sheath enlargement in acute intracranial hypertension. Neuroophthalmology 14:345354, 1994 Hansen HC, Helmke K, Kunze K: Optic nerve sheath enlargement in acute intracranial hypertension. Neuroophthalmology 14:345–354, 1994

    • Search Google Scholar
    • Export Citation
  • 16.

    Harling-Berg C, , Knopf PM, & Merriam J, et al: The role of cervical lymph nodes in the systemic humoral immune response to human serum albumin microinfused into rat cerebrospinal fluid. J Neuroimmunol 25:185193, 1989 Harling-Berg C, Knopf PM, Merriam J, et al: The role of cervical lymph nodes in the systemic humoral immune response to human serum albumin microinfused into rat cerebrospinal fluid. J Neuroimmunol 25:185–193, 1989

    • Search Google Scholar
    • Export Citation
  • 17.

    Hayreh SS: Pathogenesis of oedema of the optic disc. Doc Ophthalmol 24:289411, 1968 Hayreh SS: Pathogenesis of oedema of the optic disc. Doc Ophthalmol 24:289–411, 1968

    • Search Google Scholar
    • Export Citation
  • 18.

    Hayreh SS: The sheath of the optic nerve. Ophthalmologica 189:5463, 1984 Hayreh SS: The sheath of the optic nerve. Ophthalmologica 189:54–63, 1984

    • Search Google Scholar
    • Export Citation
  • 19.

    Hedges TR, & Zaren HA: The relationship of optic nerve tissue pressure to intracranial and systemic arterial pressure. Am J Ophthalmol 75:9098, 1973 Hedges TR, Zaren HA: The relationship of optic nerve tissue pressure to intracranial and systemic arterial pressure. Am J Ophthalmol 75:90–98, 1973

    • Search Google Scholar
    • Export Citation
  • 20.

    Helmke K, & Hansen HC: Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. I: Experimental study. Pediatr Radiol 26:701705, 1996 Helmke K, Hansen HC: Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. I: Experimental study. Pediatr Radiol 26:701–705, 1996

    • Search Google Scholar
    • Export Citation
  • 21.

    Helmke K, & Hansen HC: Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. II: Patient study. Pediatr Radiol 26:706710, 1996 Helmke K, Hansen HC: Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. II: Patient study. Pediatr Radiol 26:706–710, 1996

    • Search Google Scholar
    • Export Citation
  • 22.

    Lang J, & Reiter W: Uber praktisch-ärztlich wichtige Masse des N. opticus, des Chiasma opticum und des Tractus opticus. Gegenbaurs Morphol Jahrb 131:777795, 1985 Lang J, Reiter W: Uber praktisch-ärztlich wichtige Masse des N. opticus, des Chiasma opticum und des Tractus opticus. Gegenbaurs Morphol Jahrb 131:777–795, 1985

    • Search Google Scholar
    • Export Citation
  • 23.

    Liu D, & Kahn M: Measurement and relationship of subarachnoid pressure of the optic nerve to intracranial pressures in fresh cadavers. Am J Ophthalmol 116:548556, 1993 Liu D, Kahn M: Measurement and relationship of subarachnoid pressure of the optic nerve to intracranial pressures in fresh cadavers. Am J Ophthalmol 116:548–556, 1993

    • Search Google Scholar
    • Export Citation
  • 24.

    Liu D, & Michon J: Measurement of the subarachnoid pressure of the optic nerve in human subjects. Am J Ophthalmol 119:8185, 1995 Liu D, Michon J: Measurement of the subarachnoid pressure of the optic nerve in human subjects. Am J Ophthalmol 119:81–85, 1995

    • Search Google Scholar
    • Export Citation
  • 25.

    Marmarou A, , Shulman K, & Rosende RM: A nonlinear analysis of the cerebrospinal fluid system and intracranial pressure dynamics. J Neurosurg 48:332344, 1978 Marmarou A, Shulman K, Rosende RM: A nonlinear analysis of the cerebrospinal fluid system and intracranial pressure dynamics. J Neurosurg 48:332–344, 1978

    • Search Google Scholar
    • Export Citation
  • 26.

    McComb JG: Recent research into the nature of cerebrospinal fluid formation and absorption. J Neurosurg 59:369383, 1983 McComb JG: Recent research into the nature of cerebrospinal fluid formation and absorption. J Neurosurg 59:369–383, 1983

    • Search Google Scholar
    • Export Citation
  • 27.

    Muller PJ, & Deck JHN: Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension. J Neurosurg 41:160166, 1974 Muller PJ, Deck JHN: Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension. J Neurosurg 41:160–166, 1974

    • Search Google Scholar
    • Export Citation
  • 28.

    Oehmichen M, , Grüninger H, & Wiethölter H, et al: Lymphatic efflux of intracerebrally injected cells. Acta Neuropathol 45:6165, 1979 Oehmichen M, Grüninger H, Wiethölter H, et al: Lymphatic efflux of intracerebrally injected cells. Acta Neuropathol 45:61–65, 1979

    • Search Google Scholar
    • Export Citation
  • 29.

    Ossoinig KC: Standardized echography of the optic nerve. Doc Ophthalmol Proc Ser 55:399, 1993 Ossoinig KC: Standardized echography of the optic nerve. Doc Ophthalmol Proc Ser 55:3–99, 1993

    • Search Google Scholar
    • Export Citation
  • 30.

    Quincke H: Zur Physiologie der Cerebrospinalflüssigkeit. Arch Anat Physiol Wiss Med:153177, 1872 Quincke H: Zur Physiologie der Cerebrospinalflüssigkeit. Arch Anat Physiol Wiss Med:153–177, 1872

    • Search Google Scholar
    • Export Citation
  • 31.

    Raspanti M, , Marchini M, & Della Pasqua V, et al: Ultrastructure of the extracellular matrix of bovine dura mater, optic nerve sheath and sclera. J Anat 181:181187, 1992 Raspanti M, Marchini M, Della Pasqua V, et al: Ultrastructure of the extracellular matrix of bovine dura mater, optic nerve sheath and sclera. J Anat 181:181–187, 1992

    • Search Google Scholar
    • Export Citation
  • 32.

    Shen JY, , Kelly DE, & Hyman S, et al: Intraorbital cerebrospinal fluid outflow and the posterior uveal compartment in the hamster eye. Cell Tissue Res 240:7787, 1985 Shen JY, Kelly DE, Hyman S, et al: Intraorbital cerebrospinal fluid outflow and the posterior uveal compartment in the hamster eye. Cell Tissue Res 240:77–87, 1985

    • Search Google Scholar
    • Export Citation
  • 33.

    Whitehouse H, , Czosnyka M, & Smielewski P, et al: Blood flow velocity in the middle cerebral artery during lumbar CSF infusion tests in patients with ventricular dilatation, in Nagai H, , Kamiya K, & Ishii S (eds): Intracranial Pressure IX. New York: Springer-Verlag, 1994, pp 512513 Whitehouse H, Czosnyka M, Smielewski P, et al: Blood flow velocity in the middle cerebral artery during lumbar CSF infusion tests in patients with ventricular dilatation, in Nagai H, Kamiya K, Ishii S (eds): Intracranial Pressure IX. New York: Springer-Verlag, 1994, pp 512–513

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 813 364 50
Full Text Views 309 35 1
PDF Downloads 189 30 2
EPUB Downloads 0 0 0