Diagnosis of Elevated Intracranial Pressure in Critically Ill Adults: A Systematic Review and Meta-Analysis
CCCF ePoster library. Fernando S. 11/12/19; 285173; EP72
Dr. Shannon Fernando
Dr. Shannon Fernando
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Topic: Systematic Review, Meta-Analysis, or Meta-Synthesis

Fernando, Shannon M., MD, MSc1,2; Tran, Alexandre, MD, MSc3,4; Cheng, Wei, PhD5; Rochwerg, Bram, MD, MSc6,7; Taljaard, Monica, PhD3,5; Kyeremanteng, Kwadwo, MD, MHA1,5; English, Shane W., MD, MSc1,3,5; Sekhon, Mypinder S., MD8; Griesdale, Donald E. G., MD, MPH8,9,10; Dowlatshahi, Dar, MD, PhD3,5,11; McCredie, Victoria A., MBChB, PhD12,13; Wijdicks, Eelco F. M., MD, PhD14; Almenawer, Saleh A., MD15; Inaba, Kenji, MD16; Rajajee, Venkatakrishna, MBBS17,18; Perry, Jeffrey J., MD, MSc2,3,5.

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

Introduction: Elevated intracranial pressure (ICP) is a complication of brain injury, including traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, and ischemic stroke. Definitive diagnosis of elevated ICP is achieved through insertion of an invasive ICP monitor (intraventricular or intraparenchymal). However, invasive ICP monitoring is not available in all settings, and is associated with important complications. Therefore, clinicians often rely upon non-invasive tests (physical examination, imaging, point-of-care ultrasound, and transcranial Doppler) for diagnosis of elevated ICP.
Objectives: We conducted a systematic review and meta-analysis, with the aim of summarizing and comparing the accuracy of physical examination, computed tomography (CT), sonography of the optic nerve sheath diameter (ONSD), and transcranial doppler pulsatility index (TCD-PI) for diagnosis of elevated ICP in critically ill patients.
Methods: We searched six databases, including MEDLINE, Embase, and PubMed, from inception through September 2018. We included English-language studies investigating accuracy of physical examination, imaging or non-invasive tests among critically ill patients. Gold standard was ICP ≥ 20 mmHg using invasive ICP monitoring, or intraoperative diagnosis of raised ICP. We followed PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Two reviewers independently extracted data and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Summary estimates were generated using a Hierarchical Summary Receiver Operating Characteristic model.
Results: We included 40 studies (5,123 patients). Of physical examination signs, pooled sensitivity and specificity for increased ICP were: pupillary dilation (28.2% [95% CI: 16.0-44.8], 85.9.0% [95% CI: 74.9-92.5]), 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]). Among CT 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; and midline shift ≥ 10mm 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 (AUROC) curve for ONSD sonography was 0.94 (95% CI: 0.91-0.96). Patient-level data from studies using TCD-PI showed poor performance for detecting raised ICP (AUROC for individual studies ranging from 0.55-0.72).
Conclusions: Absence of any one physical examination feature is not sufficient to rule-out elevated ICP. Significant midline shift may suggest elevated ICP, but absence of shift cannot rule it out. ONSD sonography may have utility, but further studies are needed. Suspicion of elevated ICP may necessitate treatment and transfer, regardless of individual non-invasive tests.

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