Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
BMJ. 2019 Jul 24;366:l4225. doi: 10.1136/bmj.l4225.
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.
Systematic review and meta-analysis.
Six databases, including Medline, EMBASE, and PubMed, from inception to 1 September 2018.
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.
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.
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).
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.
PROSPERO CRD42018105642.
总结和比较体格检查、计算机断层扫描（CT）、视神经鞘直径超声检查（ONSD）和经颅多普勒搏动指数（TCD-PI）在诊断危重症患者颅内压升高（ICP）方面的准确性。
系统评价和荟萃分析。
包括 Medline、EMBASE 和 PubMed 在内的 6 个数据库，从建库至 2018 年 9 月 1 日。
研究采用体格检查、影像学或非侵入性检查来诊断危重症患者颅内压升高的准确性，以 20mmHg 或更高的 ICP 作为金标准，或采用有创 ICP 监测或术中诊断颅内压升高。
两名评审员独立提取数据，并使用诊断准确性研究质量评估工具评估研究质量。使用分层汇总受试者工作特征（ROC）模型生成汇总估计值。
共纳入 40 项研究（n=5123）。在体格检查征象中，瞳孔扩大的汇总敏感度和特异度分别为 28.2%（95%置信区间 16.0%至 44.8%）和 85.9%（74.9%至 92.5%）；去大脑强直的分别为 54.3%（36.6%至 71.0%）和 63.6%（46.5%至 77.8%）；格拉斯哥昏迷量表评分为 8 分或更低的分别为 75.8%（62.4%至 85.5%）和 39.9%（26.9%至 54.5%）。在 CT 发现中，基底池受压的敏感度和特异度分别为 85.9%（58.0%至 96.4%）和 61.0%（29.1%至 85.6%）；任何中线移位的分别为 80.9%（64.3%至 90.9%）和 42.7%（24.0%至 63.7%）；中线移位至少 10mm 的分别为 20.7%（13.0%至 31.3%）和 89.2%（77.5%至 95.2%）。OSND 超声检查的 ROC 曲线下面积（AUROC）为 0.94（0.91 至 0.96）。使用 TCD-PI 的研究中的患者水平数据显示，检测颅内压升高的性能较差（个体研究的 AUROC 范围为 0.55 至 0.72）。
任何一项体格检查特征的缺失都不足以排除颅内压升高。明显的中线移位可能提示颅内压升高，但没有移位并不能排除。OSND 超声检查可能有用，但需要进一步研究。怀疑颅内压升高可能需要进行治疗和转院，而无需考虑个体的非侵入性检查。
PROSPERO CRD42018105642。
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