Meta-Analysis

. 2019 Jul 24:366:l4225.

doi: 10.1136/bmj.l4225.

Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis

Shannon M Fernando^{1

2}, Alexandre Tran^{3

4}, Wei Cheng⁵, Bram Rochwerg^{6

7}, Monica Taljaard^{3

5}, Kwadwo Kyeremanteng^{8

5}, Shane W English^{8

3

5}, Mypinder S Sekhon⁹, Donald E G Griesdale^{9

10

11}, Dar Dowlatshahi^{3

5

12}, Victoria A McCredie^{13

14}, Eelco F M Wijdicks¹⁵, Saleh A Almenawer¹⁶, Kenji Inaba¹⁷, Venkatakrishna Rajajee^{18

19}, Jeffrey J Perry^{2

3

5}

Affiliations

¹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada sfernando@qmed.ca.
² Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
³ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
⁴ Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
⁵ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁶ Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
⁷ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
⁸ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁹ Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.
¹⁰ Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
¹¹ Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
¹² Divison of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
¹³ Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁴ Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
¹⁵ Division of Neurocritical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA.
¹⁶ Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
¹⁷ Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA.
¹⁸ Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
¹⁹ Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.

PMID: 31340932
PMCID: PMC6651068
DOI: 10.1136/bmj.l4225

Meta-Analysis

Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis

Shannon M Fernando et al. BMJ. 2019.

. 2019 Jul 24:366:l4225.

doi: 10.1136/bmj.l4225.

Authors

Affiliations

¹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada sfernando@qmed.ca.
² Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
³ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
⁴ Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
⁵ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁶ Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
⁷ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
⁸ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁹ Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.
¹⁰ Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
¹¹ Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
¹² Divison of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
¹³ Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁴ Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
¹⁵ Division of Neurocritical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA.
¹⁶ Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
¹⁷ Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA.
¹⁸ Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
¹⁹ Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.

PMID: 31340932
PMCID: PMC6651068
DOI: 10.1136/bmj.l4225

Abstract

Objectives: To summarise and compare the accuracy of physical examination, computed tomography (CT), sonography of the optic nerve sheath diameter (ONSD), and transcranial Doppler pulsatility index (TCD-PI) for the diagnosis of elevated intracranial pressure (ICP) in critically ill patients.

Design: Systematic review and meta-analysis.

Data sources: Six databases, including Medline, EMBASE, and PubMed, from inception to 1 September 2018.

Study selection criteria: English language studies investigating accuracy of physical examination, imaging, or non-invasive tests among critically ill patients. The reference standard was ICP of 20 mm Hg or more using invasive ICP monitoring, or intraoperative diagnosis of raised ICP.

Data extraction: Two reviewers independently extracted data and assessed study quality using the quality assessment of diagnostic accuracy studies tool. Summary estimates were generated using a hierarchical summary receiver operating characteristic (ROC) model.

Results: 40 studies (n=5123) were included. Of physical examination signs, pooled sensitivity and specificity for increased ICP were 28.2% (95% confidence interval 16.0% to 44.8%) and 85.9% (74.9% to 92.5%) for pupillary dilation, respectively; 54.3% (36.6% to 71.0%) and 63.6% (46.5% to 77.8%) for posturing; and 75.8% (62.4% to 85.5%) and 39.9% (26.9% to 54.5%) for Glasgow coma scale of 8 or less. Among CT findings, sensitivity and specificity were 85.9% (58.0% to 96.4%) and 61.0% (29.1% to 85.6%) for compression of basal cisterns, respectively; 80.9% (64.3% to 90.9%) and 42.7% (24.0% to 63.7%) for any midline shift; and 20.7% (13.0% to 31.3%) and 89.2% (77.5% to 95.2%) for midline shift of at least 10 mm. The pooled area under the ROC (AUROC) curve for ONSD sonography was 0.94 (0.91 to 0.96). Patient level data from studies using TCD-PI showed poor performance for detecting raised ICP (AUROC for individual studies ranging from 0.55 to 0.72).

Conclusions: Absence of any one physical examination feature is not sufficient to rule out elevated ICP. Substantial midline shift could suggest elevated ICP, but the absence of shift cannot rule it out. ONSD sonography might have use, but further studies are needed. Suspicion of elevated ICP could necessitate treatment and transfer, regardless of individual non-invasive tests.

Registration: PROSPERO CRD42018105642.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PubMed Disclaimer

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

**Fig 1**
Flowchart summarising evidence search and study selection

**Fig 2**
Pooled area under the ROC curve for diagnostic accuracy of sonography of the optic nerve sheath diameter to detect intracranial pressure of 20 mm Hg or more across studies. *Reported upper limit of 95% confidence interval not symmetrical with the lower limit in the original or logit scale. Therefore, only values with their lower confidence limits were used, and symmetry in the logit scale was assumed for the meta-analysis

**Fig 3**
Generated receiver operating characteristic curves for diagnostic accuracy of transcranial Doppler-pulsatility index for intracranial pressure of 20 mm Hg or more, as based on individual patient level data from four studies. AUROC=area under receiver operating characteristic curve

See this image and copyright information in PMC

Comment in

Review: In critically ill adults, diagnostic accuracy of noninvasive tests for detecting elevated ICP varies.
Sen A. Sen A. Ann Intern Med. 2019 Dec 17;171(12):JC68. doi: 10.7326/ACPJ201912170-068. Ann Intern Med. 2019. PMID: 31842226 No abstract available.

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Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis

Affiliations

Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Comment in

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical

Research Materials

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