Re: Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis
The authors thank Drs. Spitzer, Nicholl, and Mollan for their response to our article.
We initially sought to evaluate papilledema in our original protocol, along with the other physical examination features that we studied. Unfortunately, there was only a single study (Selhorst et al., Neurosurgery, 1985) that we could find that evaluated papilledema with a gold standard of invasive ICP monitoring. Therefore, we could not perform meta-analysis. Interestingly, in this 34-year-old study, they found that a significant proportion of patients with sustained elevations in ICP (as found on invasive monitoring) did not have papilledema on examination. Future work should evaluate the accuracy of this classically taught clinical sign.
The authors thank Drs. Lochner, Naldi, Cardim, and Robba for their comments and support of our article.
In short, we agree completely with the points that these authors have raised. The conclusions of our study were not meant to dissuade clinicians from the use of physical examination and imaging findings in critically ill patients with brain injury. Rather, we aimed to caution clinicians on the reliability of any single finding in isolation.
Future work on the derivation of a clinical decision instrument may ultimately find that a combination of these physical examination and imaging signs are highly reliable in the diagnosis of elevated intracranial pressure. Until such time, we reiterate that these signs do have value (particularly the presence of highly specific signs, such as severe midline shift), but that the absence of any single sign does not rule out the possibility of elevated ICP.
Competing interests:
No competing interests
01 September 2019
Shannon M. Fernando
Resident Physician
Alexandre Tran, Wei Cheng, Bram Rochwerg, Monica Taljaard, Kwadwo Kyeremanteng, Shane W. English, Mypinder S. Sekhon, Donald E. G. Griesdale, Dar Dowlatshahi, Victoria A. McCredie, Eelco F. M. Wijdicks, Saleh A. Almenawer, Kenji Inaba, Venkatakrishna Rajajee, Jeffrey J. Perry
Division of Critical Care, Department of Medicine, and Department of Emergency Medicine, University of Ottawa
1053 Carling Ave. E., Ottawa, ON, K1Y 4E9, Canada.
Rapid Response:
Re: Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis
The authors thank Drs. Spitzer, Nicholl, and Mollan for their response to our article.
We initially sought to evaluate papilledema in our original protocol, along with the other physical examination features that we studied. Unfortunately, there was only a single study (Selhorst et al., Neurosurgery, 1985) that we could find that evaluated papilledema with a gold standard of invasive ICP monitoring. Therefore, we could not perform meta-analysis. Interestingly, in this 34-year-old study, they found that a significant proportion of patients with sustained elevations in ICP (as found on invasive monitoring) did not have papilledema on examination. Future work should evaluate the accuracy of this classically taught clinical sign.
The authors thank Drs. Lochner, Naldi, Cardim, and Robba for their comments and support of our article.
In short, we agree completely with the points that these authors have raised. The conclusions of our study were not meant to dissuade clinicians from the use of physical examination and imaging findings in critically ill patients with brain injury. Rather, we aimed to caution clinicians on the reliability of any single finding in isolation.
Future work on the derivation of a clinical decision instrument may ultimately find that a combination of these physical examination and imaging signs are highly reliable in the diagnosis of elevated intracranial pressure. Until such time, we reiterate that these signs do have value (particularly the presence of highly specific signs, such as severe midline shift), but that the absence of any single sign does not rule out the possibility of elevated ICP.
Competing interests: No competing interests