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Letter to the Editor. Radiosurgery Is a Valuable Alternative To J Neurosurg 133:603–610, 2020 Neurosurgical Forum LETTERS TO THE EDITOR Ultrasonography of the optic ICP measurement corresponds to the evaluation of a lo- cal parameter indicative of a regional phenomenon and nerve sheath and decompressive that evaluation with the intraventricular catheter would craniectomy be more useful than that with intraparenchymal moni- tors. What was the reason for not using intraventricular ICP monitoring in the authors’ study? On the other hand, TO THE EDITOR: The evaluation of the elevation of the heterogeneity of brain injury should be taken into ac- intracranial pressure is a relevant issue during the man- count, and the authors included heterogeneous intracranial agement of patients with traumatic brain injury (TBI). 10 lesions (acute subdural hematoma, acute intracerebral he- We read the interesting article by Wang et al. in which matoma, cerebral contusion/laceration, and diffuse brain the authors share their experience with ultrasonography injury), which can alter the results. to measure the optic nerve sheath diameter, which they Finally, given the potential benefits of the application correlate with intracranial pressure (ICP), and identify of optic nerve ultrasound in patients with TBI and espe- the process as an accurate noninvasive method in patients cially in those undergoing decompressive craniectomy, with decompressive craniotomy (Wang J, Li K, Li H, et al: we suggest conducting studies in specific populations and Ultrasonographic optic nerve sheath diameter correlation multicentric studies to compare results that are relevant with ICP and accuracy as a tool for noninvasive surrogate in the management of these patients. We congratulate the ICP measurement in patients with decompressive crani- authors on their study despite the potential limitations. otomy. J Neurosurg [epub ahead of print July 19, 2019. DOI: 10.3171/2019.4.JNS183297]). Luis Rafael Moscote-Salazar, MD We have some questions that must be clarified to ex- University of Cartagena, Cartagena de Indias, Colombia trapolate and validate their results. First of all, the authors report that the patients underwent decompressive craniec- Andrei F. Joaquim, MD tomy without defining the surgical technique. Why is this State University of Campinas, Campinas-São Paulo, Brazil topic important? It has been established that the size of Amit Agrawal, MD the craniectomy influences ICP values in the postopera- Narayana Medical College Hospital, Andhra Pradesh, India tive period.7 It would be interesting to know the details of the surgical technique as this would add to the validity of the results and thus reduce the bias related to the inclusion References of patients. 1. Frumin E, Schlang J, Wiechmann W, Hata S, Rosen S, Interestingly, several studies have demonstrated the rel- Anderson C, et al: Prospective analysis of single operator evance of evaluating the optic nerve for early detection sonographic optic nerve sheath diameter measurement for of intracranial hypertension.4,6 These studies are not ex- diagnosis of elevated intracranial pressure. West J Emerg trapolated to the general population; cohorts of specific Med 15:217–220, 2014 populations are required. Acting as a confounding factor 2. Goeres P, Zeiler FA, Unger B, Karakitsos D, Gillman LM: to establish the normal diameter of the optic nerve sheath, Ultrasound assessment of optic nerve sheath diameter in healthy volunteers. J Crit Care 31:168–171, 2016 ethnicity also needs to be carefully evaluated. Ethnicity 3. Golshani K, Ebrahim Zadeh M, Farajzadegan Z, Khorvash can limit interpretation of the results and their applicabil- F: Diagnostic accuracy of optic nerve ultrasonography ity in daily practice.2,8 and ophthalmoscopy in prediction of elevated intracranial The laterality of the lesion and its correlation with the pressure. Emerg (Tehran) 3:54–58, 2015 elevation of the optic nerve sheath diameter are other rel- 4. Kimberly HH, Shah S, Marill K, Noble V: Correlation of evant aspects. This is not reported in the data presented by optic nerve sheath diameter with direct measurement of the authors. Multiple studies have reported these findings intracranial pressure. Acad Emerg Med 15:201–204, 2008 5. Roque PJ, Wu TS, Barth L, Drachman D, Khor KN, and it would be interesting to know if this was evaluated 1,3,5 Lovecchio F, et al: Optic nerve ultrasound for the detection in the study. of elevated intracranial pressure in the hypertensive patient. Compartmentalization of the ICP is another relevant Am J Emerg Med 30:1357–1363, 2012 aspect.9 It has been established that the parenchymal 6. Rosenberg JB, Shiloh AL, Savel RH, Eisen LA: Non-invasive J Neurosurg Volume 133 • August 2020 603 Unauthenticated | Downloaded 09/27/21 03:55 AM UTC Neurosurgical forum methods of estimating intracranial pressure. Neurocrit Care 0.31 ± 0.05 mm and 0.27 ± 0.03 mm in healthy volun- 15:599–608, 2011 teers and TBI patients, respectively (p = 0.53). The mean 7. Skoglund TS, Eriksson-Ritzén C, Jensen C, Rydenhag B: ONSD value was considered in the statistical analysis in Aspects on decompressive craniectomy in patients with this study. Both single (left/right)6 and mean values of traumatic head injuries. J Neurotrauma 23:1502–1509, ONSD7 were used as the parameters in different studies. 2006 8. Soldatos T, Karakitsos D, Chatzimichail K, Papathanasiou The other relevant aspect is compartmentalization of M, Gouliamos A, Karabinis A: Optic nerve sonography in the ICP. External ventricular drainage (EVD) for ICP the diagnostic evaluation of adult brain injury. Crit Care monitoring was considered as the gold standard for as- 12:R67, 2008 sessing ICP.4 Insertion of an EVD is not always possible 9. Vender J, Waller J, Dhandapani K, McDonnell D: when brain swelling causes shift or compression of the An evaluation and comparison of intraventricular, ventricles in severe TBI patients.1 While the Codman Mi- intraparenchymal, and fluid-coupled techniques for croSensor for ICP monitoring has good concordance with intracranial pressure monitoring in patients with severe the EVD5 and the MicroSensor ICP is highly accurate and traumatic brain injury. J Clin Monit Comput 25:231–236, 3 2011 stable in the tissue and subdural space, we implanted a 10. Wang J, Li K, Li H, Ji C, Wu Z, Chen H, et al: MicroSensor transducer into the subdural space to moni- Ultrasonographic optic nerve sheath diameter correlation tor ICP in our unit. Heterogeneity of brain injury defi- with ICP and accuracy as a tool for noninvasive surrogate nitely influences the ICP values, but this may not affect ICP measurement in patients with decompressive the correlation between ICP and ONSD. craniotomy. J Neurosurg [epub ahead of print July 19, 2019. The aim of this study was to assess the association be- DOI: 10.3171/2019.4.JNS183297] tween ONSD and ICP in TBI patients after a DC opera- tion. There were lots of factors influencing the ICP, such Disclosures 8 The authors report no conflict of interest. as the surgical technique, the size of craniectomy, and the heterogeneity of brain injury. We intend to evaluate Correspondence the impact factors of ICP and ONSD by expanding the Luis Rafael Moscote-Salazar: [email protected]. sample size and optimizing the study design in the future. We thank Drs. Moscote-Salazar, Joaquim, and Agrawal INCLUDE WHEN CITING for pointing out these important issues, and we wish to Published online November 22, 2019; DOI: 10.3171/2019.8.JNS192114. cooperate with them in the future. Response Juxiang Wang, MD We are grateful to Drs. Moscote-Salazar, Joaquim, Xiamen Cardiovascular Hospital, Xiamen University, and Agrawal for their interest and insightful comments Xiamen, Fujian, China regarding our article. Their first question relates to the Bin Chen, PhD surgical technique and the size of the craniotomy, both of Xiamen Port Clinic of Xiamen Customs, Xiamen, Fujian, China which may influence ICP. A larger craniotomy produced 8 a larger decrease in ICP in patients with TBI. The area of References the bone window was approximately 12 × 15 cm in uni- lateral decompressive craniotomy (DC) and about double 1. Bhatia A, Gupta AK: Neuromonitoring in the intensive care unit. I. Intracranial pressure and cerebral blood flow 12 × 15 cm in bilateral and frontal DC in our unit. The monitoring. Intensive Care Med 33:1263–1271, 2007 dura mater or artificial dura substitutes loosely covered 2. Chen H, Ding GS, Zhao YC, Yu RG, Zhou JX: Ultrasound the brain surface. Three patients with diffuse brain injury measurement of optic nerve diameter and optic nerve sheath underwent bilateral or frontal DC among the 48 TBI pa- diameter in healthy Chinese adults. BMC Neurol 15:106, tients potentially eligible for our study, and 2 died within 2015 24 hours after DC. Among the 35 ultimately enrolled pa- 3. Gray WP, Palmer JD, Gill J, Gardner M, Iannotti F: A tients, 1 underwent bilateral and 34 underwent unilateral clinical study of parenchymal and subdural miniature strain- gauge transducers for monitoring intracranial pressure. DC. We did not exclude a bilateral DC patient who had Neurosurgery 39:927–932, 1996 mildly elevated ICP. 4. Harary M, Dolmans RGF, Gormley WB: Intracranial The second question relates to optic nerve sheath di- pressure monitoring—review and avenues for development. ameter (ONSD) of the general population and ethnicity. Sensors (Basel) 18:E465, 2018 Healthy volunteers who met the physical examination cri- 5. Koskinen LO, Olivecrona M: Clinical experience with the teria underwent ultrasound examination in a calm state, intraparenchymal intracranial pressure monitoring Codman and their ICP was considered normal. These volunteers MicroSensor system. Neurosurgery 56:693–698, 2005 provided written informed consent before ONSD exami- 6. Maissan IM, Dirven PJ, Haitsma IK, Hoeks SE, Gommers D, 2 Stolker RJ: Ultrasonographic measured optic nerve sheath nation. diameter as an accurate and quick monitor for changes in We agree that the laterality of the lesion influences the intracranial pressure.
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