J Neurosurg 109:255–258, 2008

Effect of intracranial pressure on the diameter of the optic

nerve sheath
Arata Watanabe, M.D., Ph.D.,1 Hiroyuki Kinouchi, M.D., Ph.D.,1
Toru Horikoshi, M.D., Ph.D.,1 Mikito Uchida, M.D., Ph.D.,1
and Keiichi Ishigame, M.D., Ph.D.2

Departments of 1Neurosurgery and 2Radiology, Faculty of Medicine, University of Yamanashi,

Chuo, Yamanashi, Japan

Object. The subarachnoid space around the optic nerve in the orbit can be visualized using T2-weighted MR im-
aging with the fat-saturation pulse sequence. The optic nerve sheath (ONS) diameter can be estimated by measuring
the outer diameter of the subarachnoid space. Dilated ONS is associated with idiopathic intracranial hypertension
and hydrocephalus, and is believed to reflect increased intracranial pressure (ICP). The relationship between dilated
ONS and ICP is unclear because of the difficulty in obtaining noninvasive measurements of ICP. The authors inves-
tigated the relationship between subdural pressure measured at the time of surgery and ONS diameter measured on
MR images in patients with chronic subdural fluid collection.
Methods. Twelve patients underwent bur-hole craniostomy with continuous drainage for chronic subdural he-
matoma or hygroma in 2006. Orbital thin-slice fat-saturated MR images were obtained before and after surgery, and
the ONS diameters were measured just behind the optic globe. Subdural pressure was measured using a manometer
before opening of the dura mater.
Results. A significant correlation was found between the ONS diameter and the subdural pressure (correlation
coefficient 0.879, p = 0.0036). The ONS diameter before surgery (6.1 ± 0.7 mm) was significantly reduced after sur-
gery (4.8 ± 0.9 mm, p = 0.003; measurements are expressed as the mean ± standard deviation).
Conclusions. Increased ONS diameter measured on coronal orbital thin-slice fat-saturated T2-weighted MR im-
ages is a strong indicator of increased ICP, and helps to differentiate between passive subdural fluid collection due to
brain atrophy and subdural hygroma with increased ICP. (DOI: 10.3171/JNS/2008/109/8/0255)

Key Words      •      chronic subdural hematoma      •      intracranial pressure      •     

optic nerve sheath      •      subarachnoid space      •      subdural pressure

I
ncreased ICP is an important indicator for surgical
intervention to treat lesions that are causing mass ef-
fect. Lumbar puncture is a simple way to measure the
ICP, but carries the risk of inducing brain herniation in
patients with raised pressure. Several devices to measure
ICP have been invented, but their use requires invasive
procedures.17 Superior ophthalmic vein enlargement as-
sociated with diffuse cerebral swelling noted on high-res-
olution CT scans may be an indirect result of increased
ICP.8 Dilation of the superior ophthalmic vein (especially
by > 2.5 mm) detected on MR imaging11 and CSF flow
and blood flows measured at the craniocervical junction
Abbreviations used in this paper: CSDH = chronic subdural
he­matoma; CSF = cerebrospinal fluid; ICP = intracranial pressure;
ON = optic nerve; ONS = ON sheath.
by using MR imaging are also possible methods to de-
tect increased ICP.1,5,14 However, ICP remains difficult to
evaluate using only neuroimaging methods.
Dilation of the ONS may be associated with idio-
pathic intracranial hypertension or hydrocephalus, indi-
cating increased ICP.2,4,7 The subarachnoid space around
the ON in the orbit can be detected using T2-weighted
MR imaging with the fat-saturation pulse sequence.10,16
This technique can differentiate CSF in the subarachnoid
space around the ON from the surrounding fat tissue as
high-intensity circles on the coronal images. The ONS
diameter can be evaluated by measuring the outer diam-
eter of the subarachnoid space.
In the present study we investigated the potential use
of ONS diameter as a possible marker of ICP by using
fat-saturated orbital MR imaging to measure the corre-
lation between ICP and ONS diameter in patients with
CSDH or hygroma.

J. Neurosurg. / Volume 109 / August 2008 255

 A. Watanabe et al.

Methods Statistical Analysis

Patient Population
This study included 12 patients, 9 men and 3 wom-
en between 21 and 90 years of age (mean age 73 years),
who underwent bur-hole surgery with continuous drain-
age for CSDH or subdural hygroma in 2006. Patients in
whom fine orbital MR images were not obtained because
of motion artifacts, or with inaccurate measurement of
subdural pressure because of glutinous fluid or leakage
of fluid through the puncture site before measurement,
were excluded. The MR imaging was performed in 12
patients within 24 hours before surgery and follow-up
studies were obtained in 8 patients between 1 week and 4
months after surgery.
Evaluation With MR Imaging
Fat-saturated T2-weighted fast spin echo MR im-
ages of the orbit were obtained using a 1.5-T MR unit
(GE Medical Systems) with TR 3500 msec, TE 100 msec,
flip angle 90°, slice thickness 3.5 mm, slice gap 0.3 mm,
matrix 320 × 224, field of view 16 × 16 cm, echo train
length 12, and bandwidth 31.2 kHz. The ONS diameter
was measured just behind the optic globe.
Subdural Pressure Measurement
Patients were positioned to locate the bur hole posi-
tion at the highest point with 15° of head elevation. To
prevent subdural fluid leakage through the puncture site,
the dura mater was punctured using a 23-gauge needle
and then the subdural pressure was measured. In patients
with bilateral lesions, the thicker side was treated first,
and the subdural pressure was measured in this side. Af-
ter measurement of the subdural pressure, the dura mater
was opened and the drainage tube was placed in the sub-
dural space.
The Spearman rank correlation was calculated to as-
sess the correlation between ONS diameter and subdural
pressure. The Student t-test was performed to compare
the ONS diameter before and after surgery, and differenc-
es in the two-tailed t-test at probability values of less than
0.05 were considered to be significant. Measurements are
expressed as the mean ± standard deviation.
Results
Table 1 summarizes the measurements of ONS di-
ameter and subdural pressure. The mean ONS diameter in
the 12 patients before surgery (6.1 ± 0.7 mm) was signifi-
cantly decreased after surgery in 7 patients (4.8 ± 0.9 mm,
p = 0.003). The ONS diameter could not be measured 1
week postsurgery because of collapse of the subarachnoid
space in 1 patient. The association between the ONS di-
ameter and the subdural pressure is shown in Fig. 1. The
approximate curve is expressed as
y = 0.00079x3 − 0.03929x2 + 0.64216x + 2.3062,
r2 = 0.834
There was a significant correlation between these vari-
ables (correlation coefficient 0.879, p = 0.0036).
Representative Case
This 75-year-old man (Case 5) was referred to our
institute after a diagnosis of left CSDH. He had a his-
tory of minor head injury that had occurred 1 month be-
fore admission. Neurological examination revealed right
hemiparesis without papilledema. Brain CT and MR im-
aging studies showed left CSDH. Orbital imaging showed
the dilated ONS. The ONS diameter just behind the optic
globe was 6 mm on the right and 6.1 mm on the left (Fig.
2A). He underwent bur hole craniostomy for CSDH. Sub-
dural pressure before opening the dura mater was 21 cm

TABLE 1
Summary of measurements of the ONS diameter and subdural pressure*
Initial Findings Follow-Up Findings

Diameter of
ONS (mm) Diameter of ONS (mm)
Case Age (yrs), Side & Type Subdural Pressure Measurement
No. Sex of Lesion Lt Rt Avg (cm H2O) Lt Rt Avg Interval

1 79, F bilat hygroma 5.2 5.7 5.4 9 4.9 4.8 4.9 1 wk

2 85, F lt CSDH 5.6 5.5 5.6 9 2.9 3.1 3.0 3 mos
3 89, F lt CSDH 5.7 5.9 5.8 12 5.2 5.8 5.5 1 wk
4 67, M rt CSDH 5.4 5.7 5.6 17 4.4 5.0 4.7 3 mos
5 75, M lt CSDH 6.1 6.0 6.1 21 4.3 4.9 4.6 3 mos
6† 64, M bilat hygroma 6.1 6.2 6.1 25 collapsed collapsed collapsed 1 wk
7 80, M lt CSDH 5.2 6.5 5.8 26 NA NA NA NA
8 78, M lt CSDH 6.2 6.6 6.4 26 5.2 5.1 5.2 4 mos
9 21, M bilat hygroma 7.6 8.5 8.0 30 5.5 6.0 5.7 2 mos
10 90, M bilat CSDH 5.7 5.7 5.7 11 NA NA NA NA
11 61, M bilat CSDH 7.1 6.7 6.9 30 NA NA NA NA
12 90, M rt CSDH 5.6 5.5 5.6 12 NA NA NA NA
* Avg = average; NA = not available.
† Diameter could not be measured at 1 week postsurgery because the subarachnoid space had collapsed.

256 J. Neurosurg. / Volume 109 / August 2008

Optic nerve sheath and intracranial pressure
Fig. 1.  Graph showing the association between the subdural
pressure and the diameter of the ONS.
H2O. The dura was then opened and a drainage tube was
placed in the subdural space for 1 day. His right hemipa-
resis resolved. Brain MR imaging performed 3 months
later showed disappearance of the CSDH, and orbital MR
imaging demonstrated decreased ONS diameter of 4.9
mm on the right and 4.3 mm on the left (Fig. 2B).
Discussion
In this study we found a significant correlation be-
Fig. 2.  Case 5. High-resolution, thin-section, T2-weighted MR images of the orbit obtained with the fat-saturated
fast spin echo sequences.  A: The diameter of the ONS (arrows) just behind the optic globe was 6 mm on the right
and 6.1 mm on the left before surgery.  B: Three months after the operation, the diameter of the ONS (arrows) had
decreased to 4.9 mm on the right and 4.3 mm on the left.
J. Neurosurg. / Volume 109 / August 2008
tween the ONS diameter and the ICP, confirming the
observations of dilated ONS in patients with increased
ICP.4,7,12 The normal ONS diameters just behind and 4
mm posterior to the globe are 5.52 ± 1.11 mm and 5.2
± 0.9 mm, respectively;10,16 are consistent through all
eyeball positions; and are relatively stable in individu-
als.10,15 In our study, the ONS diameter was measured as
5.4–8 mm (mean 6.1 ± 0.7 mm) and subdural pressure as
9–30 cm H2O (mean 19 ± 8.2 cm H2O) before surgery.
The diameter of the ONS decreased to 3–5.7 mm (mean
4.8 ± 0.9 mm) after full recovery from symptoms. We
propose a normal limit of diameter just behind the eye-
ball of 5.8 mm, because the upper normal limit of ICP
has been considered to be ~ 20 cm H2O, and this numeri-
cal value was applied to the aforementioned approximate
curve. Therefore, an ONS diameter of > 6 mm indicates
an abnormally high ICP of > 20 cm H2O.
Follow-up MR imaging performed 1 week after sur-
gery in 3 patients clearly showed that the ONS diameters
were reduced. Such a rapid change in the ONS diameter
indicates an immediate reflection of changes in ICP. The
ONS is reported to have sufficient elasticity to allow de-
tectable dilation in response to a change in the ICP, which
was confirmed by measuring the ONS diameter with se-
rial B-mode ultrasonography scans during the intrathecal
infusion test.6
Subdural pressure is well correlated with lumbar
257

pressure.13 Subdural pressure measured by subdural screw
monitor insertions is correlated with ventricular flu­id
pressure in patients with head injuries.3 However, no cor-
relation is known between ventricular and subdural pres-
sure in patients with CSDH. The subdural and ventricular
pressures may differ because CSDH is encapsulated by a
membrane. The compliance of the membrane may cause
a pressure gradient. Therefore, one of the limitations of
this study is the measurement of the subdural pressure
rather than the ventricular pressure.
The subarachnoid space of the ON is anatomically
classified into the bulbar segment, intraorbital segment,
and canalicular portion. These divisions are not uniform,
and the subarachnoid space is distinct at the bulbar seg-
ment in healthy individuals.9 The ONS diameter varies
at different points of measurement,10,16 so the measuring
point should be consistent. In addition, variable depiction
of the ON, CSF, and ONS depending on the MR sequence
has been reported,16 so MR imaging with consistent pa­
ram­eters is also important.
Conclusions
Measurement of the ONS diameter on coronal orbital
thin-slice fat-saturated T2-weighted MR images has the
potential to indicate abnormally high ICP in patients with
subdural hygroma, which is sometimes difficult to dis-
tinguish from brain atrophy. Further study is needed to
clarify the differences depending on an individual’s, age,
sex, and race, and to establish this method as an accurate
indicator of ICP.
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Manuscript submitted February 7, 2007.
Accepted October 25, 2007.
Sources of support: none reported.
Address correspondence to: Arata Watanabe, M.D., Ph.D.,
De­partment of Neurosurgery, Faculty of Medicine, University of
Ya­ma­nashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan.
email: arata@yamanashi.ac.jp.
J. Neurosurg. / Volume 109 / August 2008