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

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✓ 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.

Article Information

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

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph (upper) and ultrasonography scans (lower) showing original data from a 74-year-old patient with headache and papilledema after sinus venous thrombosis who underwent lumbolumbar perfusion testing (Group A, Case 1; Rout 8 mm Hg/ml/minute). Scans of the right ON were obtained during constant- and zero-flow conditions. Scans 2 to 7 refer to a flow rate of 1 ml/minute; 11 to 19, 2 ml/minute; 24 to 39, 3 ml/minute; and 42 to 55, 4 ml/minute. The remaining scans correspond to test intervals with zero flow rates. The graph shows the course of CSF pressure (CSFP, closed circles) and ONS diameter (ONSD, open circles) for 66 consecutive scans. Note the consistent change in ONS diameter above a CSF pressure of 20 mm Hg and its close relation to CSF pressure variations up to 50 mm Hg. In the typical examples of ONS ultrasonography scans (lower), the echolucent band represents the ON together with its sheath. The measurements of ONS diameter were obtained by placing cursors 3 mm behind the posterior orbital wall. Note the clear display of papilledema in most of the projections and reversible expansion of the ONS in correlation to the CSF pressure.

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    Summary scatterplot of all 12 patients after data normalization by z transformation (655 datapoints). Linear regression (center line) demonstrates the close relationship between ONS diameter (ONSD) and CSF pressure ([CSFP], r2 = 0.752). Outer lines correspond to the 95% confidence bounds.

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    Graphs showing response to intrathecal infusion as monitored by ON sonography (left) and lumbar CSF pressure (CSFP) registration (right). Steady-state ONS diameter (ONDS) and CSF pressure are plotted versus the applied flow rate (milliliters/minute). Pressure changes are reflected in corresponding variations in the ONS diameter, especially in the low flow—rate range. Subgroup comparison shows that ONS diameter progression is more pronounced in patients with elevated Rout (Group B, closed circles) than with normal Rout (Group A, open circles). By comparing the steady-state ONS diameter at an intermediate flow rate (for example at 2 ml/minute), the presence of elevated Rout can be individually predicted (borderline ONS diameter 5 mm).

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