Research

Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis

Shannon M Fernando, Alexandre Tran, Wei Cheng, et al

BMJ 2019;366:l4225

Abstract

Objectives 背景

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.

总结并比较体格检查，CT，视神经鞘直径(ONSD)超声及经颅多普勒脉动指数(TCD-PI)对危重病患者高颅压(ICP)的诊断准确性。

Design 设计

Systematic review and meta-analysis.

系统回顾及meta分析

Data sources 数据来源

Six databases, including Medline, EMBASE, and PubMed, from inception to 1 September 2018.

直至2018年9月1日，检索包括Medline, EMBASE, 和 PubMed 在内的6个数据库。

Study selection criteria 研究选择标准

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.

针对危重病患者体格检查、影像学或无创检测准确性的英文研究。参照标准为有创监测ICP大于等于20 mm Hg，或术中诊断高ICP。

Data extraction 数据提取

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.

2名作者独立提取数据，并采用诊断准确性研究质量评估工具评价研究质量。采用分层汇总ROC模型评估综合估计值。

Results 结果

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).

供纳入40项研究(n=5123)。其中，体格检查所发现体征诊断高ICP的汇总敏感性和特异性分别为，瞳孔扩大 28.2% (95% 可信区间 16.0% to 44.8%) 和 85.9% (74.9% to 92.5%)； 动作异常 54.3% (36.6% to 71.0%) 和 63.6% (46.5% to 77.8%) for posturing; 格拉斯哥昏迷评分小于等于8分75.8% (62.4% to 85.5%) 和 39.9% (26.9% to 54.5%)。在各种CT表现中，环池受压的诊断敏感性和特异性分别为 85.9% (58.0% to 96.4%) 和 61.0% (29.1% to 85.6%)；任何程度的中线移位 80.9% (64.3% to 90.9%) 和 42.7% (24.0% to 63.7%) ；中线移位至少10 mm 20.7% (13.0% to 31.3%) 和 89.2% (77.5% to 95.2%)。ONSD超声检查汇总AUROC为 0.94 (0.91 to 0.96)。使用TCD-PI研究的患者水平数据发现，检测高ICP的准确性较差（各项研究的AUROC 0.55 - 0.72）。

Conclusions 结论

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.

体格检查未发现任何特征性表现不足以排除高ICP。明显的中线移位提示高ICP，但没有中线移位不能排除。ONSD超声检查可能有帮助，但是需要进一步研究。无论采用何种无创检查方法，怀疑高ICP时应当开始治疗。

Registration 研究注册

PROSPERO CRD42018105642.