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

BMJ 2019; 366 doi: (Published 24 July 2019) Cite this as: BMJ 2019;366:l4225
  1. Shannon M Fernando, resident physician1 2,
  2. Alexandre Tran, resident physician3 4,
  3. Wei Cheng, senior methodologist5,
  4. Bram Rochwerg, assistant professor6 7,
  5. Monica Taljaard, associate professor3 5,
  6. Kwadwo Kyeremanteng, assistant professor1 5,
  7. Shane W English, assistant professor1 3 5,
  8. Mypinder S Sekhon, assistant professor8,
  9. Donald E G Griesdale, associate professor8 9 10,
  10. Dar Dowlatshahi, associate professor3 5 11,
  11. Victoria A McCredie, assistant professor12 13,
  12. Eelco F M Wijdicks, professor14,
  13. Saleh A Almenawer, assistant professor15,
  14. Kenji Inaba, professor16,
  15. Venkatakrishna Rajajee, associate professor17 18,
  16. Jeffrey J Perry, professor2 3 5
  1. 1Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
  2. 2Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
  3. 3School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
  4. 4Department of Surgery, University of Ottawa, Ottawa, ON, Canada
  5. 5Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
  6. 6Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
  7. 7Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
  8. 8Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
  9. 9Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
  10. 10Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
  11. 11Divison of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
  12. 12Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
  13. 13Toronto Western Hospital, University Health Network, Toronto, ON, Canada
  14. 14Division of Neurocritical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA
  15. 15Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
  16. 16Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
  17. 17Department of Neurology, University of Michigan, Ann Arbor, MI, USA
  18. 18Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
  1. Correspondence to: S M Fernando, Department of Emergency Medicine and Department of Critical Care Medicine, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada sfernando{at} (or @shanfernands on Twitter)
  • Accepted 30 May 2019


Objectives 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.

Design Systematic review and meta-analysis.

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

Study selection criteria 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.

Data extraction 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.

Results 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).

Conclusions 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.

Registration PROSPERO CRD42018105642.


  • Contributors: SMF, AT, and JJP conceived the study idea. SMF, AT, WC, BR, and JJP coordinated the systematic review. SMF and AT designed the search strategy, screened abstracts and full texts, acquired the data, and judged risk of bias in the studies. WC performed the data analysis. BR created the GRADE evidence profiles. All authors interpreted the data analysis and critically revised the manuscript. All authors had the opportunity to review the final manuscript, and provided their permission to publish the manuscript. All authors agree to take responsibility for the work. SMF is guarantor. The corresponding author attests that all listed authors meet authorship criteria, and that no others meeting the criteria have been omitted.

  • Funding: None received.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethics approval: Not applicable.

  • Data sharing: The Meta-DAS SAS macro (recommended by the Cochrane handbook for systematic reviews of diagnostic test accuracy) is available at and is also available from the corresponding author.

  • The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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