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

Shannon M Fernando; Alexandre Tran; Wei Cheng; Bram Rochwerg; Monica Taljaard; Kwadwo Kyeremanteng; Shane W English; Mypinder S Sekhon; Donald E G Griesdale; Dar Dowlatshahi; Victoria A McCredie; Eelco F M Wijdicks; Saleh A Almenawer; Kenji Inaba; Venkatakrishna Rajajee; Jeffrey J Perry

doi:10.1136/bmj.l4225

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

BMJ. 2019 Jul 24:366:l4225. doi: 10.1136/bmj.l4225.

Authors

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.

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.

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Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Systematic Review

MeSH terms

Critical Illness*
Humans
Intracranial Hypertension / diagnosis*
Physical Examination / methods
Reproducibility of Results
Tomography, X-Ray Computed
Ultrasonography, Doppler, Transcranial / methods