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MP07: Diagnosis of elevated intracranial pressure in critically ill adults – a systematic review and meta-analysis

Published online by Cambridge University Press:  02 May 2019


S. Fernando
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
A. Tran
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
W. Cheng
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
B. Rochwerg
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
M. Taljaard
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
K. Kyeremanteng
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
S. English
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
M. Sekhon
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
D. Griesdale
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
D. Dowlatshahi
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
M. Czosnyka
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
V. McCredie
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
E. Wijdicks
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
S. Almenawer
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
K. Inaba
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
V. Rajajee
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON
J. Perry
Affiliation:
University of Ottawa, Department of Emergency Medicine, Ottawa, ON

Abstract

Introduction: Elevated intracranial pressure (ICP) is a devastating complication of brain injury, such as traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, and other conditions. Delay to diagnosis and treatment are associated with increased morbidity and mortality. For Emergency Department (ED) physicians, invasive ICP measurement is typically not available. We sought to summarize and compare the accuracy of physical examination, imaging, and ultrasonography of the optic nerve sheath diameter (ONSD) for diagnosis of elevated ICP. Methods: We searched Medline, EMBASE and 4 other databases from inception through August 2018. We included only English studies (randomized controlled trials, cohort and case-control studies). Gold standard was ICP≥20 mmHg on invasive ICP monitoring. Two reviewers independently screened studies and extracted data. We assessed risk of bias using Quality Assessment of Diagnostic Accuracy Studies 2 criteria. Hierarchical Summary Receiver Operating Characteristic model generated summary diagnostic accuracy estimates. Results: We included 37 studies (n = 4,768, kappa = 0.96). Of exam signs, pooled sensitivity and specificity for increased ICP were: mydriasis (28.2% [95% CI: 16.0-44.8], 85.9.0% [95% CI: 74.9-92.5]), motor posturing (54.3% [95% CI: 36.6-71.0], 63.6% [95% CI: 46.5-77.8]) and Glasgow Coma Scale (GCS) ≤8 (75.8% [95% CI: 62.4-85.5], 39.9% [95% CI: 26.9-54.5]). Computed tomography findings: compression of basal cisterns had 85.9% [95% CI: 58.0-96.4] sensitivity and 61.0% [95% CI: 29.1-85.6] specificity; any midline shift had 80.9% [95% CI: 64.3-90.9] sensitivity and 42.7% [95% CI: 24.0-63.7] specificity; midline shift≥1cm had 20.7% [95% CI: 13.0-31.3] sensitivity and 89.2% {95% CI: 77.5-95.2] specificity. Finally, pooled area under the ROC curve describing accuracy for ONSD sonography for ICP was 0.94 (95% CI: 0.91-0.96). Conclusion: The absence of any one physical exam feature (e.g. mydriasis, posturing, or decreased GCS) is not sufficient to rule-out elevated ICP. Significant midline shift is highly suggestive of elevated ICP, but absence of shift does not rule it out. ONSD sonography may be useful in diagnosing elevated ICP. High suspicion of elevated ICP may necessitate treatment and transfer to a centre capable of invasive ICP monitoring.


Type
Moderated Poster Presentations
Copyright
Copyright © Canadian Association of Emergency Physicians 2019 

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