Optic Nerve Sheath Diameter is not Related to Intracranial Pressure in Subarachnoid Hemorrhage Patients

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A Letters to the editor to this article was published on 17 July 2020

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Intracranial pressure (ICP) monitoring is essential after subarachnoid hemorrhage (SAH) to prevent secondary brain insults and to tailor individualized treatments. Optic nerve sheath diameter (ONSD), measured using ultrasound (US), could serve as a noninvasive bedside tool to estimate ICP, avoiding the risks of hemorrhage or infection related to intracranial catheters. The aims of this study were twofold: first, to explore the reliability of US for measuring ONSD; second, to establish whether the US-ONSD can be considered a proxy for ICP in SAH patients early after bleeding. For the first aim, we compared the ONSD measurements given by magnetic resonance imaging (MRI-ONSD) with the US-ONSD findings. For the second aim, we analyzed the relationship between US-ONSD measurements and ICP values.


Adult patients with diagnosis of aneurysmal SAH and external ventricular drainage system (EVD) were included. Ten patients were examined by MRI to assess ONSD, and the results were compared to the diameter given by US. In 20 patients, the US-ONSD values were related to ICP measured simultaneously through EVD. In ten of these patients, we explored the changes in the US-ONSD at the time of controlled and fairly rapid changes in ICP after cerebrospinal fluid (CSF) drainage.


US-ONSD measurements at the bedside were accurate, very similar to the diameters measured by MRI (the mean difference in the Bland–Altman plot was 0.08 mm, 95% limits of agreement: − 1.13; + 1.23 mm). No clear relationship was detectable between the ICP and US-ONSD, and a linear regression model showed an angular coefficient very close to 0 (p > 0.05). US-ONSD and ICP values were in agreement after CSF drainage and shifts in ICP in a limited number of patients.


US-ONSD measurement does not accurately estimate ICP in SAH patients in the intensive care unit.

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The authors appreciate the support of Dr. Luca Neri and Dr. Carmela Graci who offered their help for ultrasound training. The authors are grateful for the cooperation of Dr. Alessandra Merrino who helped in the acquisition of data and for the support of Dr. EJA Wiegers who helped in data analysis.


Support was provided by funds from Ricerca Corrente of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico.

Author information




NS, AC, TZ, and MC conceived and designed the study. AC, TZ, NS, ED, GC, SA, FT, and TB contributed to data analysis and interpretation. TZ, NS, AC, MC, FO, and ERZ critically revised the manuscript.

Corresponding author

Correspondence to Tommaso Zoerle.

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The authors declare that they have no conflict of interest in relation to this manuscript.

Ethical approval/informed consent

The institutional review board of the hospital (Ethics Committee Milan, Zone 1) approved the study, and written consent was obtained according to the regulations applied in our Institution. Number: ATTI 774/2016 - 24.05.2016

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This work was performed at the Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.

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Zoerle, T., Caccioppola, A., D’Angelo, E. et al. Optic Nerve Sheath Diameter is not Related to Intracranial Pressure in Subarachnoid Hemorrhage Patients. Neurocrit Care 33, 491–498 (2020). https://doi.org/10.1007/s12028-020-00970-y

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  • Optic nerve sheath
  • Intracranial pressure
  • Subarachnoid hemorrhage
  • Ultrasonography
  • Magnetic resonance imaging