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1、,解剖学基础,解剖学基础,Pulillary aperature 瞳孔 Iris 虹膜 Cornea 角膜 Ciliary body 睫状体 Lens 晶状体 Vitreous body 玻璃体 Retina 视网膜 Choroid 脉络膜 Sclera 巩膜,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。测量主要在眼球后3mm处，因为该处随颅内压变化的弹性伸缩性最大。,测量方法,探头的选择和放置,1 选择高频线阵探头 (7.5 MHz or greater) . 2 无菌贴膜覆盖眼球 3 充分耦合，避免挤压眼球（以面颊或者额头为受力点） 4 深度在视网膜下1-
2、2cm,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部3mm 2 分别测量长轴和短轴的视神经鞘直径并求出平均值。 3 测量对侧视神经鞘的直径。 It is imperative to acquire a true on-axis, longitudinal cross section of the optic nerve sheath because off-axis ima ging results in erroneous measurement of the ONSD.,参考值,1、 单侧异常,The presence of unilateral increased O
3、NSD suggests a lateralizing process, such as optic neuritis or compressive optic neuropathy. Papill edema（视乳头水肿） may also be noted as optic disc bulging into the retina and protruding into the vitreous body.,2、 双侧异常,The cutoff value for increased ONSD correlating with increased ICP has been debatabl
4、e. Based on the initial study of ultrasound measurement of ONSD,11 many authors cite a diameter 5 mm as elevated in patients older than age 4. Two recent meta-analyses of six studies evaluated the correlation between ONSD and ICP 20 cm H2O and calculated a pooled sensitivity and specificity of 8790%
5、 and 7985%, respectively; however, the cutoff for abnormal ONSD varied from 5.0 to 5.9 mm in these studies, with half of the studies utilizing a cutoff 5.7 mm.,临床应用,视神经鞘直径#可准确评估颅内压增高,视神经鞘直径#可准确预测心肺复苏的结局,After adjustment on predictive factors, ONSD1 was significantly associated with in-hospital morta
6、lity (OR 6.3; 95%CI 1.05-40 per mm of ONSD1 above 5.5mm; p=0.03), and CPC score (OR for 1 point increase in CPC score: 3.2; 95%CI 1.2-9.4 per mm of ONSD1 above 5.5mm; p=0.03). ONSD1 was significantly correlated with brain edema assessed by the cerebrum gray matter attenuation to white matter attenua
7、tion ratio, measured by the brain computed tomography scan performed on admission in 20 patients (Spearman rho=-0.5, p=0.04). Resuscitation. 2016 Jun;103:7-13. doi: 10.1016/j.resuscitation.2016.03.006. Epub 2016 Mar 16.,视神经鞘直径#脑功能监护,The optic nerve sheath diameter has been verified by various clinic
8、al studies as a non-invasive indicator of intracranial hypertension. The aim of this study was to compare the optic nerve sheath diameter before and immediately after ventriculo-peritoneal shunt surgery in children with hydrocephalus. We analysed transorbital ultrasonographic images recorded after i
9、nduction of anaesthesia and 30 min after shunt insertion in 34 children, measuring the optic nerve sheath diameters using a linear ultrasound probe. The mean (SD) optic nerve sheath diameters were 5.4 (0.6) mm (right) and 5.3 (0.7) mm (left) before surgery and 4.4 (0.5) mm (right) and 4.5 (0.7) mm (
10、left) after surgery (p 0.0001 for before and after comparisons for both eyes). The technique allows rapid and non-invasive assessment of intracranial pressure to guide appropriate postoperative management. Anaesthesia. 70(11):1268-1273, November 2015.,ONSD 0.8cm 0.82cm提醒医生既是检查发现了未知原因的脑梗死大小3cm2cm,评估第
11、三脑室底部造瘘术的标准之一,Optic nerve sheath diameter as criteria for endoscopic third ventriculostomy failure in children.,影响因素,1 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
12、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 su
13、pine 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 intracrani
14、al hypertension who require prone positioning.,Journal of Neurosurgical Anesthesiology. 18 March 2016,2 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 wer
15、e 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 at baseline (p = 0.01), 5.4 and 6.2 mm at 15 min (p = 0.01), 5.8 and 6.6 mm at 30 min (p = 0.01), and 5.1 and 5.7 mm after deflation of pneumoperitoneum (p = 0.03), respectively.,Surgical Endoscopy June 2016, Volume 30, Issue 6, pp 23212325,Point-of-Care Ultrasound,谢谢,