The aim of our study is to test the hypothesis whether ultrasonographically measured ultrasound-guided optic nerve sheath diameter (US-ONSD) decreases after lumbar puncture (LP) and whether decreased optic nerve sheath diameter (ONSD) after lumbar puncture is associated with headache. The latter might help to identify patients with postdural puncture headache (PDPH). In this prospective observational study 76 patients, who had undergone diagnostic LP using an atraumatic technique, received a measurement of ONSD before (T0), immediately after (T1) and 24 h after LP (T2). Additionally demographic data such as age, sex, body mass index (BMI), and also headaches and symptoms were recorded. In six out of 7 patients with constant PDPH, we additionally measured ONSD 48 h (T3) and 72 h (T4) after LP. All patients (n = 76, 100%) showed a physiological reduction in ONSD at T1. Patients with consistent symptoms of PDPH (n = 7, 9%) kept values below pre-LP levels after 24 and 48 h. No statistical difference was found in BMI, sex, cerebrospinal fluid volume, needle size, or previous headaches between the PDPH (n = 7, 9%) and non-PDPH patients (n = 69, 91%). Younger patients were more likely to experience PDPH symptoms. Since at T2 the ONSD was only reduced in PDPH patients, a significant difference in ONSD was found between PDPH and non-PDPH patients. The cut-off value of ONSD for predicting PDPH at T2 was 4.9 mm in the receiver operating characteristic (ROC) curve (sensitivity 86%, specificity 93%). We were able to demonstrate a physiologic change in ONSD after LP in all patients. The sonographic measurement of ONSD in patients with headache can help to identify and monitor PDPH after LP.

Using ferric chloride (FeCl3) to induce experimental superior sagittal sinus (SSS) thrombosis might interfere with magnetic resonance imaging (MRI)-assisted visualization and evaluation of the thrombus, the brain parenchyma, and the quality of the occlusion. The aim of this study was to investigate whether aluminum chloride (AlCl3)-induced thrombosis of the SSS has comparable properties to those of FeCl3 without causing artifacts in MRI. SSS thrombosis was induced in 14 male Wistar rats by exposure of the SSS and subsequent topical application of a filter paper strip soaked in AlCl3 (n = 7) or FeCl3 (n = 7) over a period of 15 min. The animals with AlCl3-induced SSS thrombosis showed a constant and complete occlusion with in histological analysis large thrombi. Blood flow measurements indicated a significant reduction on the first and seventh postoperative day compared to preoperative measurements. MRI enabled visualization and subsequent evaluation of the thrombus and the surrounding parenchyma. In comparison, FeCl3-induced SSS thrombosis could not be evaluated by MRI due to artifacts caused by the paramagnetic properties and increased susceptibility of FeCl3. The occluded sinus and the surrounding area appeared hypointense. The quality of SSS occlusion by AlCl3 was comparable to that of FeCl3. AlCl3 therefore represents a significant alternative substance in experimental SSS thrombosis ideally suited for studies using MRI.

This review summarizes the relationship between intracranial pressure and the venous system as far as ultrasound methods are concerned. Although the pressure in cortical veins is tightly and linearly coupled to the intracranial pressure, venous flow velocities in the basal veins are not. However, venous flow velocities reflect better the local cerebral blood flow than measurements in arteries. Therefore, they correlate better with clinical outcome in head trauma and subarachnoid hemorrhage. Transorbital sonography with measurement of the optic nerve sheath diameter and optic disk elevation has evolved to a valuable point of care diagnostic tool in idiopathic intracranial hypertension. In cerebral vein and sinus thrombosis ultrasound is at best a supplementary diagnostic tool, which may have a value in patient follow-up.

This review summarizes the relationship between intracranial pressure and the venous system as far as ultrasound methods are concerned. Although the pressure in cortical veins is tightly and linearly coupled to the intracranial pressure, venous flow velocities in the basal veins are not. However, venous flow velocities reflect better the local cerebral blood flow than measurements in arteries. Therefore, they correlate better with clinical outcome in head trauma and subarachnoid hemorrhage. Transorbital sonography with measurement of the optic nerve sheath diameter and optic disk elevation has evolved to a valuable point of care diagnostic tool in idiopathic intracranial hypertension. In cerebral vein and sinus thrombosis ultrasound is at best a supplementary diagnostic tool, which may have a value in patient follow-up.

To assess the value of optic nerve sheath diameter (ONSD) measurements at different time points to predict the malignant evolution in middle cerebral artery (MCA) infarction and to investigate the relationship between ONSD and infarct volume on follow-up computed tomography (CT). In a single-center prospective observational study, we recruited patients with MCA infarction and age- and sex-matched controls. Clinical characteristics including NationaI Institutes of Health Stroke Scale (NIHSS) and ONSD measurement were assessed during the first five days after symptom onset. Volumetric analysis of the infarction was performed by a neuroradiologist, who was blinded to results of ONSD measurement and clinical examinations, based on  CT scans. We enrolled 29 patients with MCA infarction, including 10 with malignant MCA (mMCA) infarction and 14 controls. Mean ONSD on admission was already larger in patients who had developed an mMCA (5.99 ± 0.32 mm) compared to patients with MCA infarction (4.98 ± 0.53 mm; P = 0.003), and to control patients (4.57 ± 0.29 mm; P < 0.001). Correlation was observed between the ONSD mean value bilateral measures per individual and volumetric evaluation of cerebral infarction in the CT scan after one day (r = 0.623; P = 0.002). An ONSD value of 5.6 mm predicted an mMCA with a sensitivity of 100% and specificity of 90% yielding a positive predictive value of 83% and negative predictive value of 100%. ONSD measurement might be accurate for the noninvasive detection of increased ICP and for the recognition of patients being likely to develop mMCA.

The aim of this study was to evaluate the feasibility of ocular ultrasound in the follow-up of pseudotumor cerebri syndrome and to correlate ultrasound with clinical parameters. In a cohort study of 22 consecutive adult patients, ocular ultrasound was performed measuring optic nerve sheath diameter, optic nerve diameter, and optic disc elevation compared with symptoms referred by the patients. The patients showed increased optic nerve sheath diameter [median, 6.51 mm (interquartile range 6.13–7.10)], optic nerve diameter [3.02 mm (2.86–3.27)], and optic disc elevation [0.90 mm (0.64–1.36)] at the time of admission and had ophthalmologically confirmed the presence of papilledema in all 22 patients. After 6 months all parameters decreased significantly for optic nerve sheath diameter [6.08 mm (5.59–6.73), P = 0.002], optic nerve diameter [2.87 mm (2.70–3.15), P = 0.007], and optic disc elevation [0.48 mm (0.30–0.70), P < 0.001]. In addition, a discrete negative correlation between optic nerve sheath diameter and headache change after 6 months was observed with ρ = − 0.477 and P = 0.02. No correlation was found between optic disc elevation and headache. In conclusion, longitudinal follow-up with ocular ultrasound combined with clinical information may provide support for treatment of this condition.

Background and Purpose— Pregnancy is associated with increased risk of venous thrombotic events, including cerebral venous thrombosis. We aimed to study the complications and outcome of subsequent pregnancies in women with previous cerebral venous thrombosis. Methods— Follow-up study of women with acute cerebral venous thrombosis at childbearing age included in a previously described cohort (International Study of Cerebral Vein and Dural Sinus Thrombosis). Patients were interviewed by local neurologists to assess rate of venous thrombotic events, pregnancy outcomes, and antithrombotic prophylaxis during subsequent pregnancies. Results— A total of 119 women were included, with a median follow-up of 14 years. Eighty-two new pregnancies occurred in 47 women. In 83% (68 of 82), some form of antithrombotic prophylaxis was given during at least 1 trimester of pregnancy or puerperium. Venous thrombotic events occurred in 3 pregnancies, including 1 recurrent cerebral venous thrombosis. Two of the 3 women were on prophylactic low-molecular-weight heparin at the time of the event. Outcomes of pregnancies were 51 full-term newborns, 9 preterm births, 2 stillbirths, and 20 abortions (14 spontaneous). Conclusions— In women with prior cerebral venous thrombosis, recurrent venous thrombotic events during subsequent pregnancies are infrequent.

AbstractUltrasonography of the extra- and intracranial vessels has been an essential part of the approved concept of stroke units in Germany. This review aims to highlight unique selling points of neurosonology in the acute phase of stroke.In acute ischemic stroke, occlusion or stenosis of an arterial segment induces individually variable and complex changes in cerebral hemodynamics. Acute arterial occlusion may persist, may partially or completely recanalize, re-occlude after initial recanalization or may be compensated by collateral blood flow. Ultrasonography is most suitable to monitor these hemodynamic changes in the early stages of a stroke. The earlier neurosonography is performed, the better the pathophysiological understanding is, and the more targeted are therapeutic efforts to limit acute neurovascular injury. A general view is that CT angiography and/or magnetic resonance imaging and neurosonographical techniques in acute stroke care are competitive and interchangeable. However, these methods are rather complementary since the visualization of blood vessels, cerebral perfusion and hemodynamic flow is based on different physical principles. Each method has particular advantages and limitations. With respect to the specific diagnostic question, one method or the other may be indicated. It is the responsibility of the treating neurologist to select the most appropriate imaging method and to provide specific competence in neurosonography. The main scope of this article is to motivate neurologists to apply neurosonography specifically in the acute phase of stroke in order to get an independent assessment and unique hemodynamic information instead of leaving neurovascular competence to radiologists. Purposeful use of neurosonologic techniques makes the difference in high quality stroke care.

ZusammenfassungDie Untersuchung der hirnversorgenden Arterien mittels Doppler- und Duplexsonografie war bislang fester Bestandteil des bewährten Stroke-Unit-Konzepts. Dies hat sich mit der Neufassung der Schlaganfall-OPS geändert: neurosonografische Untersuchungen während der Stroke-Unit-Behandlung sind im Falle der Durchführung einer CT- bzw. MR-Angiografie nicht mehr gefordert. Nach Eintritt eines ischämischen Schlaganfalls laufen im betroffenen Gefäßsegment und den dazugehörigen Kollateralwegen komplexe, individuell unterschiedliche, hämodynamische Umstellungsprozesse ab, die für das Schicksal des Patienten entscheidend sind. Verschlüsse können persistieren, partiell oder komplett rekanalisieren, kollateral kompensiert werden oder nach Rekanalisation wieder re-okkludieren. Diese Prozesse in den ersten Stunden können mittels Ultraschall wie mit keiner anderen Methode verfolgt werden. Je früher die Untersuchung erfolgt, desto aufschlussreicher sind die Befunde, desto besser ist das pathophysiologische Verständnis und desto größer ist der individuelle Nutzen für therapeutische Entscheidungen. Vielfach werden CTA, MRA und Ultraschall in der Schlaganfallversorgung als kompetitive Methoden begriffen. In Wahrheit handelt es sich aber um komplementäre Verfahren, mit denen auf der Basis von sehr unterschiedlichen physikalischen Prinzipien Bilder erzeugt und Blutgefäße, Hirnperfusion und Blutflüsse dargestellt werden. Mit Blick auf eine spezielle klinische Fragestellung ist jeweils das eine oder andere Verfahren indiziert. Es obliegt dem klinisch verantwortlichen Neurologen hier die richtige Auswahl zu treffen und spezifische neurosonologische Kompetenz einzubringen. Ziel dieser Übersichtsarbeit ist es, Neurologinnen und Neurologen dazu zu motivieren, Neurosonologie speziell in der Akutphase des Schlaganfalls einzusetzen um sich selbst ein Bild zu machen, anstatt sich „ein Bild machen zu lassen“.

Transorbital sonography (TOS) has been proven to be able to non-invasively detect elevated intracranial pressure. In this condition TOS shows an increase in optic nerve sheath diameter (ONSD). It has been suggested that internal jugular vein valve insufficiency (IJVVI) may represent a factor contributing to the pathogenesis of idiopathic intracranial hypertension (IIH). The aim of this study was to investigate whether patients with IIH or secondary IH have higher ONSD values and higher frequency of IJVVI compared to subjects without IH.