Correlation of diameter of the optic nerve sheath and clinical outcomes in patients with intracerebral hemorrhage based on the intracerebral hemorrhage score

Year 2025, Volume: 42 Issue: 3, 234 - 241, 30.09.2025

Rizkidawati Rizkidawati , Farida Farida , Sri Hastuti , Fauzul Husna , Syahrul Syahrul , Nur Astini , Zulkarnain Zulkarnain

Abstract

Hemorrhagic stroke is classified according to its anatomical location into intracerebral, subarachnoid, and intraventricular hemorrhages. Increased intracerebral pressure (ICP) can result in poor outcomes in patients with hemorrhagic stroke. Ultrasonography (USG) of the optic nerve sheath diameter (ONSD) has been suggested as a noninvasive method for detecting elevated ICP. Previous studies have indicated that an ONSD greater than 5 mm correlates with an ICP > 20 mmHg. This study aimed to examine the relationship between ONSD and clinical outcomes in intracerebral hemorrhagic stroke patients with ICH according to the intracerebral hemorrhage (ICH) score. This observational cross-sectional study was conducted from March to June 2021 at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia, and included 52 patients with acute intracerebral hemorrhage stroke patients. Each patient underwent brain CT, and ICH scores were obtained upon admission. ONSD sonography was performed 48 h after admission. Fisher's exact test was used to examine the relationship between ONSD and clinical outcomes, whereas Spearman’s rank correlation coefficient was used to assess the strength of the correlation. A strong positive correlation was found between ONSD and ICH scores (r = 0.618, p < 0.000). The significant components of the ONSD-associated ICH score were the GCS score (p = 0.001), ICH volume (p = 0.000), and the presence of IVH (p = 0.009). This study concluded that ONSD was a non-invasive and cost-effective method to assess increased ICP in patients with intracerebral hemorrhagic stroke, showed a correlation with clinical outcomes according to the ICH score.

Keywords

Optic nerve sheath diameter , intracerebral hemorrhagic stroke , USG , clinical outcome , ICH score

Ethical Statement

This study was approved by the Health Research Ethics Committee of the Faculty of Medicine, Universitas Syiah Kuala-Dr. Zainoel Abidin General Hospital (RSUZA), Banda Aceh, Indonesia (No. 069/EA/FK-RSUZA/2021, March 17, 2021).

Thanks

The authors would like to thank the patients at Dr. Zainoel Abidin General Hospital (RSUZA), Banda Aceh who participated in this study.

References

• Boccardi E, Cenzato M, Curto F, Longoni M, Motto C, Oppo V, et al. Hemorrhagic Stroke. In: Elio Agostoni, editor. Emergency Management in Neurology Series. Switzerland: Springer International Publishing; 2019.
• Ovbiagele B. Intracerebral Hemorrhage Therapeutics: Concepts and Customs. Qureshi AI, editor. San Fransisco: Springer International Publishing AG; 2018. 1–171 p.
• Badan Penelitian dan Pengembangan Kesehatan Kemenkes RI. Riset Kesehatan Dasar (Riskesdas) [Internet]. Jakarta; 2018. Available from: https://www.litbang.kemkes.go.id/laporan-riset-kesehatan-dasar-riskesdas/
• Almeida T, Almeida F, Giacomini L V, Niederauer A, Cho A, Mallmann AB, et al. Epidemiological Profile of Intracerebral Hemorrhage During a 10-Year Period in a Southern Brazilian Region. Arquivos Brasileiros De Neurocirurgia Brazilian Neurosurgery. 2018;37(01):7–12.
• Affandi IG, Panggabean R. Pengelolaan Tekanan Tinggi Intrakranial pada Stroke. CDK-238. 2016;43:180–4. Hemphill III JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032–60.
• Papalini EP. Optic nerve: Measure the diameter of its sheath to detect intracranial hypertension. Rev Bras Oftalmol. 2018 Mar;77(2):68–71.
• Patel R, Chowdhury MAB, Gul S, Fahy BG, Gonzalez AA, Fitzpatrick D, et al. Ultrasound of Optic Nerve Sheath Diameter and Stroke Outcomes. Crit Care Explor. 2021;3(11):e0565.
• Cultrera D, Pratesi M. Ultrasonography of the Optic Nerve. In: Sarti A, Lorini FL, editors. Textbook of Echocardiography for Intensivists and Emergency Physicians [Internet]. Cham: Springer International Publishing; 2019. p. 561–3. Available from: https://doi.org/10.1007/978-3-319-99891-6_57
• Kozacı N, Avcı M, Caliskan G, Yüksel S. Variability of Optic Nerve Sheath Diameter in Acute Ischemic Stroke. Hong Kong Journal of Emergency Medicine. 2019;27(4):223–8.
• Seyedhosseini J, Aghili M, Vahidi E, Shirani F. Association of optic nerve sheath diameter in ocular ultrasound with prognosis in patients presenting with acute stroke symptoms. Turkish J Emerg Med. 2019;19(4):132–5.
• Finocchi C, Balestrino M, Malfatto L, Mancardi G, Serrati C, Gandolfo C. National Institutes of Health Stroke Scale in patients with primary intracerebral hemorrhage. Neurological Sciences. 2018;39:1751–5.
• Liu C, Zhang H, Wang L, Jiang Q, Lu E, Yuan C, et al. Irregular Shape as an Independent Predictor of Prognosis in Patients With Primary Intracerebral Hemorrhage. 2021;
• Cummock JS, Wong KK, Volpi JJ, Wong ST. Reliability of the National Institutes of Health (NIH) Stroke Scale Between Emergency Room and Neurology Physicians for Initial Stroke Severity Scoring. Cureus. 2023 Apr; Mehta R, Chinthapalli K. Glasgow coma scale explained. BMJ. 2019;365.
• American Academy of CME. National Institutes of Health Stroke Scale (NIHSS) [Internet]. 2021 [cited 2025 March 28]. Available from: http://www.nihstrokescale.org/
• Ur N, Siddiqui R, Haque A, Abbas Q, Jurair H, Salam B, et al. Ultrasonographic Optic Nerve Sheath Diameter Measurement For Raised Intracranial Pressure in A Tertiary Care Centre of A Developing Country. J Ayub Med Coll Abbottabad. 2018;30(4).
• Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH Score. Stroke. 2001;32(4):891–7.
• Houben R, Schreuder FH, Bekelaar K, Claessens D, Oostenbrugge RJ v., Staals J. Predicting Prognosis of Intracerebral Hemorrhage (ICH): Performance of ICH Score Is Not Improved by Adding Oral Anticoagulant Use. Front Neurol. 2018;9.
• Shushrutha Hedna V, Rastogi V, Weeks E, Patel RP. Abstract W MP83: Use of Optic Nerve Sheath Diameter in Emergency Department to Predict Stroke Outcome. In: Stroke. Am Heart Assoc; 2015. p. AWMP83–AWMP83.
• Dias FA, Barreira CM, Zontin MCZ, Alessio-Alves FF, Martins RK, Boulouis G, et al. Dilated optic nerve sheath diameter by trans-orbital ultrasound predicts mortality among patients with acute intracerebral hemorrhage. In: Stroke. Philadelphia: Lippincott Williams & Wilkins Two Commerce SQ; 2019.
• Nathani A, Ghamande S, Kambhampati S, Anderson B, Lohse MR, White HD. The Use of POCUS-Obtained Optic Nerve Sheath Diameter in Intracerebral Hemorrhage. Pocus Journal. 2023;8(2):170–4.
• Mukherjee N, El-Dairi MA, Tariq Bhatti M. Optic Nerve Sheath Fenestration--Indications and Techniques. US Ophthalmic Rev. 2013;6(2).
• Richards E, Munakomi S, Mathew D. Optic Nerve Sheath Ultrasound [Internet]. 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554479/
• Haque A, Abbas Q, Jurair H, Salam B, Sayani R. Ultrasonographic optic nerve sheath diameter measurement for raised intracranial pressure in a tertiary care centre of a developing country. Journal of Ayub Medical College. 2018;30(4):495.
• Amini A, Kariman H, Dolatabadi AA, Hatamabadi HR, Derakhshanfar H, Mansouri B, et al. Use of the sonographic diameter of optic nerve sheath to estimate intracranial pressure. Am J Emerg Med. 2013;31(1):236–9.
• Lochner P, Mader C, Nardone R, Tezzon F, Zedde ML, Malferrari G, et al. Sonography of the optic nerve sheath beyond the hyperacute stage of intracerebral hemorrhage. J Ultrasound. 2014;17:225–8.
• Tarzamni MK, Derakhshan B, Meshkini A, Merat H, Fouladi DF, Mostafazadeh S, et al. The diagnostic performance of ultrasonographic optic nerve sheath diameter and color Doppler indices of the ophthalmic arteries in detecting elevated intracranial pressure. Clin Neurol Neurosurg. 2016;141:82–8.
• Bhide M, Singh O, Juneja D, Goel A. Bedside ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure in nontraumatic neuro-critically ill patients. World J Crit Care Med. 2023;12(1):10.
• Lee SH. Stroke Revisited: Hemorrhagic Stroke. Springer; 2018.
• Lapchak PA, Yang GY. Translational research in stroke. Springer; 2017.
• Lee S, Kim YO, Baek JS, Ryu JA. The prognostic value of optic nerve sheath diameter in patients with subarachnoid hemorrhage. Crit Care. 2019;23:1–9.
• Hemphill III JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891–7.
• Putra MPJ, Sani AF, Lestari P, Ardhi MS. Bleeding Volume, Blood Pressure, and Consciousness Level in Association with the Mortality Rate among Patients with Intracerebral Hemorrhage at Dr. Soetomo General Hospital, Surabaya. Althea Medical Journal. 2020;7(2):51–4.
• Marisi VS. Korelasi tingkat keparahan stroke dengan volume perdarahan dan diameter optic nerve sheath secara CT Scan (Studi pada pasien stroke hemoragik) [Internet]. [Semarang]: Dipenogoro University; 2019. Available from: https://lib.undip.ac.id/index.php?p=show_detail&id=2214&in=Fakultas%20Kedokteran
• Naldi A, Pivetta E, Coppo L, Cantello R, Comi C, Stecco A, et al. Ultrasonography monitoring of optic nerve sheath diameter and retinal vessels in patients with cerebral hemorrhage. Journal of Neuroimaging. 2019;29(3):394–9.
• Školoudík D, Herzig R, Fadrná T, Bar M, Hradílek P, Roubec M, et al. Distal enlargement of the optic nerve sheath in the hyperacute stage of intracerebral haemorrhage. British journal of ophthalmology. 2011;95(2):217–21.
• Trifan G, Arshi B, Testai FD. Intraventricular hemorrhage severity as a predictor of outcome in intracerebral hemorrhage. Front Neurol. 2019;10:217.
• Cardim D, Czosnyka M, Chandrapatham K, Badenes R, Bertuccio A, Noto A Di, et al. Effects of age and sex on optic nerve sheath diameter in healthy volunteers and patients with traumatic brain injury. Front Neurol. 2020;11:764.
• Yang W, Feng Y, Zhang Y, Yan J, Fu Y, Chen S. Volume quantification of acute infratentorial hemorrhage with computed tomography: validation of the formula 1/2ABC and 2/3SH. PLoS One. 2013;8(4):e62286.
• Arifin I, Kaelan C, Akbar M, Muis A, Tammasse J, Ganda IJ. Mortalitas pasien strok perdarahan intraserebral menggunakan skor intracerebral hemorrhage di Makassar. Universitas Hasanuddin. 2014;
• Panchal HN, Shah MS, Shah DS. Intracerebral hemorrhage score and volume as an independent predictor of mortality in primary intracerebral hemorrhage patients. Indian Journal of Surgery. 2015;77(Suppl 2):302–4.
• Dias FA, Zotin MCZ, Alessio-Alves FF, do Vale Martins Filho RK, Barreira CMA, Vincenzi OC, et al. Dilated optic nerve sheath by ultrasound predicts mortality among patients with acute intracerebral hemorrhage. Arq Neuropsiquiatr. 2023;81(10):861–7.