视神经鞘直径与颅内压课件

视神经鞘直径(ONSD)与颅内压(ICP)重症医学科视神经鞘直径(ONSD)与颅内压(ICP)重症医学科解剖学基础解剖学基础解剖学基础解剖学基础Pulillary aperature Pulillary aperature 瞳孔瞳孔Iris Iris 虹膜虹膜Cornea Cornea 角膜角膜Ciliary body Ciliary body 睫状体睫状体Lens Lens 晶状体晶状体Vitreous body Vitreous body 玻璃体玻璃体Retina Retina 视网膜视网膜Choroid Choroid 脉络膜脉络膜Sclera Sclera 巩膜巩膜解剖学基础Pulillary aperature 瞳孔视神经鞘直径与颅内压课件眼部结构及超声图像眼部结构及超声图像 眼球眼球及眶周结构及眶周结构视神经鞘直径与颅内压课件视神经鞘直径与颅内压课件 视路视路MRIMRI图像图像 视神经：视神经：眼内部眶部（ONSD段）管内部颅内部 视路MRI图像 视神经：视神经鞘直径与颅内压课件Critical Care 2008,12:R114ONSD视神经ONSD临界值5.82mm ICP20mmHg Critical Care 2008,12:R114ONS共纳入231例敏感性 0.90（95%CI 0.80-0.95）特异性 0.85（95%CI 0.73-0.93）Intensive Care Med(2011)37:10591068共纳入231例Intensive Care Med(201视神经鞘直径与颅内压课件ConclusionsConclusions Sonographic measurement of ONSD may be a Sonographic measurement of ONSD may be a potentially useful techniquepotentially useful technique for assessing IH in a for assessing IH in a binary mode(present/absent)when binary mode(present/absent)when invasive/monitoring methods are not desirable or invasive/monitoring methods are not desirable or availableavailable.Conclusions视神经鞘直径可准确评估颅内压增视神经鞘直径可准确评估颅内压增高？高？视神经鞘直径可准确评估颅内压增高？视神经鞘直径与颅内压课件ConclusionConclusion This study suggests that ONSD assessment This study suggests that ONSD assessment throughout the acute phase may not be a reliable throughout the acute phase may not be a reliable method to monitor ICP.method to monitor ICP.ONSD expansion can ONSD expansion can persist even after ICP controlpersist even after ICP control,and this may be,and this may be the reason for ONSD expansions seen in our the reason for ONSD expansions seen in our study even with normal ICPs.Further larger size study even with normal ICPs.Further larger size studies are needed to confirm these findings.studies are needed to confirm these findings.Conclusion影响因素影响因素1、体位体位Effects of Prone Position and Positive End-Expiratory Pressure on Noninvasive Estimators of ICP:A Pilot Study.Results:The mean values of ONSD,ICPFVd,and ICPPI significantly increased after change from supine to prone position.Receiver operating characteristic analyses demonstrated that,among the noninvasive methods,the mean ONSD measure had the greatest area under the curve signifying it is the most effective in distinguishing a hypothetical change in ICP between supine and prone positioning(0.86+/-0.034 0.79 to 0.92).A cutoff of 0.43 cm was found to be a best separator of ONSD value between supine and prone with a specificity of 75.0 and a sensitivity of 86.7.Conclusions:Noninvasive ICP estimation may be useful in patients at risk of developing intracranial hypertension who require prone positioning.Journal of Neurosurgical Anesthesiology.18 March 2016 1、体位Effects of Prone Position2 肥胖、气腹肥胖、气腹There were 62 subjects,28 females(45.2%)and 34 males(54.8%),with a mean age of 44.22 10.44 years(range 2366).Forty-eight percent of patients were non-obese,and 52%of patients were obese.The mean body mass index was 30.70 7.61 kg/m2(range 20.059.5).The mean ONSD of non-obese and obese patients was 4.7 and 5.5 mm 4.7 and 5.5 mm at baseline(p=0.01),5.4 and 6.2 mm 5.4 and 6.2 mm at 15 min(p=0.01),5.8 5.8 and 6.6 mm and 6.6 mm at 30 min(p=0.01),and 5.1 and 5.7 mm 5.1 and 5.7 mm after deflation of pneumoperitoneumpneumoperitoneum(p=0.03),respectively.Surgical EndoscopyJune 2016,Volume 30,Issue6,pp 232123252 肥胖、气腹There were 62 subjects,测量方法测量方法探头的选择和放置探头的选择和放置 1 1 选择高频线阵探头选择高频线阵探头(7.5 MHz or greater).(7.5 MHz or greater).2 2 无菌贴膜覆盖眼球无菌贴膜覆盖眼球 3 3 充分耦合，避免挤压眼球（以面颊或者额头为受力点）充分耦合，避免挤压眼球（以面颊或者额头为受力点）4 4 深度在视网膜下深度在视网膜下1-2cm1-2cm探头的选择和放置1 选择高频线阵探头(7.5 MHz or视神经鞘直径与颅内压课件测量的方法和注意事项测量的方法和注意事项 1 1 测量位置：位于视网膜和视神经交界处深部测量位置：位于视网膜和视神经交界处深部3mm3mm 2 2 分别测量长轴和短轴的视神经鞘直径并求出平均值。分别测量长轴和短轴的视神经鞘直径并求出平均值。3 3 测量对侧视神经鞘的直径。测量对侧视神经鞘的直径。测量的方法和注意事项1 测量位置：位于视网膜和视神经交界处深 视神经鞘是颅内硬脑膜与蛛网膜下腔的延续，视神经鞘是颅内硬脑膜与蛛网膜下腔的延续，视神经鞘是颅内硬脑膜与蛛网膜下腔的延续，视神经鞘是颅内硬脑膜与蛛网膜下腔的延续，因此颅内压增高将直接增大视神经鞘直径。测量因此颅内压增高将直接增大视神经鞘直径。测量因此颅内压增高将直接增大视神经鞘直径。测量因此颅内压增高将直接增大视神经鞘直径。测量主要在眼球后主要在眼球后主要在眼球后主要在眼球后3mm3mm处，因为该处随颅内压变化的处，因为该处随颅内压变化的处，因为该处随颅内压变化的处，因为该处随颅内压变化的弹性伸缩性最大。弹性伸缩性最大。弹性伸缩性最大。弹性伸缩性最大。视神经鞘是颅内硬脑膜与蛛网膜下腔的延续，因此颅内ONSD评估颅内压力测量方法：冠状位测量球后3mm处ONSD,3次均值正常上限值5mm矢状位测量球后3mm 处ONSD,3次均值正常上限值5.8mm视神经鞘直径与颅内压课件参考值参考值1、单侧异常单侧异常 The presence of unilateral increased ONSD suggests a The presence of unilateral increased ONSD suggests a lateralizing process,such lateralizing process,such as optic neuritis or as optic neuritis or compressive optic neuropathycompressive optic neuropathy.Papill edemaPapill edema（视乳头水肿）（视乳头水肿）may also be noted as optic may also be noted as optic disc bulging into the retina and protruding into the disc bulging into the retina and protruding into the vitreous body.vitreous body.1、单侧异常The presence of unilate2、双侧异常双侧异常 The cutoff value for increased ONSD correlating with The cutoff value for increased ONSD correlating with increased ICP has been debatable.increased ICP has been debatable.Based on the initial study of ultrasound measurement of Based on the initial study of ultrasound measurement of ONSD,11 many authors cite a ONSD,11 many authors cite a diameter 5 mm as diameter 5 mm as elevated in patients older than age 4.elevated in patients older than age 4.Two recent meta-analyses of six studies evaluated the Two recent meta-analyses of six studies evaluated the correlation between ONSD and correlation between ONSD and ICP 20 cm H2O ICP 20 cm H2O and and calculated a pooled sensitivity and specificity of 8790%calculated a pooled sensitivity and specificity of 8790%and 7985%,respectively;however,and 7985%,respectively;however,the cutoff for the cutoff for abnormal ONSD varied from 5.0 to 5.9 mm in these abnormal ONSD varied from 5.0 to 5.9 mm in these studies,with half of the studies utilizing a cutoff studies,with half of the studies utilizing a cutoff 5.7 mm.5.7 mm.2、双侧异常The cutoff value for in谢谢聆听！谢谢聆听！