Abstract
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.
Data availability
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
Abbreviations
- BMI:
-
Body mass index
- CSF:
-
Cerebrospinal fluid
- CT:
-
Computed tomography
- ICP:
-
Intracranial pressure
- IIH:
-
Idiopathic intracranial hypertension
- LP:
-
Lumbar puncture
- MRI:
-
Magnetic resonance imaging
- NRS:
-
Numerical rating scale
- ONS:
-
Optic nerve sheath
- ONSD:
-
Optic nerve sheath diameter
- PDPH:
-
Postdural puncture headache
- ROC:
-
Receiver operating characteristic
- SD:
-
Standard deviation
- SIH:
-
Spontaneous intracranial hypotension
- TOS:
-
Transorbital sonography
- US-ONSD:
-
Ultrasound-guided optic nerve sheath diameter
References
Cheema, S. et al. Spontaneous intracranial hypotension. Pract. Neurol. 24, 98–105 (2024).
Jacobs, M. B. & Wasserstein, P. H. Spontaneous intracranial hypotension. An uncommon and underrecognized cause of headache. West. J. Med. 155, 178–180 (1991).
Knodel, S. et al. Sonographic and ophthalmic assessment of optic nerve in patients with idiopathic intracranial hypertension: A longitudinal study. J. Neurol. Sci. 430, 118069 (2021).
Lochner, P. et al. Optic nerve sheath diameter: present and future perspectives for neurologists and critical care physicians. Neurol Sci 40, 2447–2457 (2019).
Robba, C. et al. Optic nerve sheath diameter measured sonographically as non-invasive estimator of intracranial pressure: A systematic review and meta-analysis. Intensive Care Med. 44, 1284–1294 (2018).
Beşir, A., Tertemiz, O. F., Akdoğan, A. & Duman, E. N. The importance of optic nerve sheath diameter in post-dural puncture headache diagnosis and follow-up. Noro Psikiyatr. Ars. 56, 195–199 (2019).
Boyacı, S., Onay, M. & Güleç, M. S. Optic nerve sheath diameter measurement for prediction of postdural puncture headache. J. Clin. Monit. Comput. 38, 415–422 (2024).
Peng, Q. et al. The value of the optic nerve sheath diameter (ONSD) in predicting postdural puncture headache (PDPH): A prospective observational study. Pain Physician 26, 45–52 (2023).
Fichtner, J. et al. Management of spontaneous intracranial hypotension - Transorbital ultrasound as discriminator. J. Neurol. Neurosurg. Psychiatry 87, 650–655 (2016).
Schott, C. K. et al. Ultrasound measurement of optic nerve sheath diameter pre- and post-lumbar puncture. The Ultrasound J. 12, 26 (2020).
Chen, L.-M. et al. Ultrasonic measurement of optic nerve sheath diameter: a non-invasive surrogate approach for dynamic, real-time evaluation of intracranial pressure. Br. J. Ophthalmol. 103, 437–441 (2019).
Wang, L.-J. et al. Ultrasonographic optic nerve sheath diameter as a noninvasive marker for intracranial hypotension. Ther. Adv. Neurol. Disord. 15, 17562864211069744 (2022).
Bäuerle, J., Lochner, P., Kaps, M. & Nedelmann, M. Intra- and interobsever reliability of sonographic assessment of the optic nerve sheath diameter in healthy adults. J. Neuroimaging 22, 42–45 (2012).
Hirzallah, M. I. et al. Quality assessment of optic nerve sheath diameter ultrasonography: Scoping literature review and Delphi protocol. J. Neuroimaging 32, 808–824 (2022).
Hirzallah, M. I. et al. Optic nerve sheath diameter point-of-care ultrasonography quality criteria checklist: An International Consensus Statement on Optic Nerve Sheath Diameter Imaging and Measurement. Crit. Care Med. 52, 1543–1556 (2024).
Lochner, P. et al. Ocular ultrasound for monitoring Pseudotumor cerebri syndrome. J. Neurol. 265, 356–361 (2018).
Al-Hashel, J., Rady, A., Massoud, F. & Ismail, I. I. Post-dural puncture headache: A prospective study on incidence, risk factors, and clinical characterization of 285 consecutive procedures. BMC Neurol. 22, 261 (2022).
Marzola, F. et al. Development of a deep learning-based system for optic nerve characterization in transorbital ultrasound images on a multicenter data set. Ultrasound Med. Biol. 49, 2060–2071 (2023).
Dubost, C. et al. Increase in optic nerve sheath diameter induced by epidural blood patch: A preliminary report. Br. J. Anaesth. 107, 627–630 (2011).
Ahmed, I. et al. Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept study. Eur. J. Anaesthesiol. 38, 777–784 (2021).
Acknowledgements
We appreciate the valid assistance of Martin Lesmeister in editing the manuscript.
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Open Access funding enabled and organized by Projekt DEAL.
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F.M. and P.L. drafted the original manuscript. A.-L.K., D.J., J.V., B.L., S.R., L.S. and S.K. were responsible for data acquisition. F.M., E.S., V.V. and P.L. analysed the data. D.J. performed the statistical analyses. A.-L.K. prepared the figures. All authors reviewed and edited the manuscript.
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This article contains a prospective observational study performed by authors with human participants. It was conducted at the Neurology Department of a University Hospital. The local ethics committee (Ethikkommission der Ärztekammer des Saarlandes; no. 208/23) approved the study. All procedures were according to the ethical standards of the committee responsible for human experimentation (institutional and national) and the Helsinki Declaration of 1975, revised in 2013. Written informed consent was obtained from each participant or legal guardian.
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Merzou, F., Kunzmann, AL., Janitschke, D. et al. Ultrasound measurement of optic nerve sheath diameter pre and post lumbar puncture for prediction of postdural puncture headache. Sci Rep (2026). https://doi.org/10.1038/s41598-026-40311-1
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DOI: https://doi.org/10.1038/s41598-026-40311-1
