Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 36959

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : UC51 - UC55 Full Version

Ultrasonographic Measurement of Optic Nerve Sheath Diameter in Patients Undergoing Open Heart Surgery: A Prospective Cross-sectional Study

Published: June 1, 2022 | DOI:
PD Vivek, VS Joshi, Anil Kumar, HN Madhusudana

1. Assistant Professor, Department of Anaesthesia, Command Hospital, Bengaluru, Karnataka, India. 2. Senior Advisor and Head, Department of Anaesthesia, Command Hospital, Bengaluru, Karnataka, India. 3. Consultant and Head, Department of Cardiology, 7 Air Force Hospital, Kanpur, Uttar Pradesh, India. 4. Professor, Department of Anaesthesia, 7 Air Force Hospital, Kanpur, Uttar Pradesh, India.

Correspondence Address :
Dr. HN Madhusudana,
Professor, Department of Anaesthesia, 7 Air Force Hospital, Kanpur-208004, Uttar Pradesh, India.


Introduction: Adverse neurologic outcomes following cardiac surgery can be catastrophic to the patient, next of kin, healthcare facility and community at large. Ultrasonographic measurement of Optic Nerve Sheath Diameter (ONSD) has emerged as a promising modality to reflect Intracranial Pressure (ICP) and neurological status in various neurological settings.

Aim: To explore ONSD as a tool to reflect ICP changes and predict neurologic outcomes in a cardiac surgical perioperative setting during Cardiopulmonary Bypass (CPB).

Materials and Methods: This was an open-label, prospective and observational study conducted in Department of Anaesthesia, Command Hospital, Karnataka, India, from June 2016 to July 2018. All patients aged between 15 and 80 years who underwent open heart surgeries irrespective of gender, primary diagnosis and preoperative American society of Anaesthesiologist’s Physical Status (ASA PS) grade were enrolled in the study. Serial ultasonographic ONSD of both eyes in two planes (viz. sagittal and transverse) were acquired by a single observer at the following time intervals: baseline (prior to general anaesthesia induction, immediately postintubation, and every 15 minutes interval during CPB (until 150 minutes or end of the CPB whichever was earlier). Postoperative neurologic reassessment was done at 6 hours/postextubation (whichever earlier), at 24 hours and after 7 days, postoperatively. Continuous variables were compared using the student t-tests, while Chi-square or Fisher’s-exact test was used to compare categorical variables. To assess inter-rater reliability for categorical variables, the Cohen’s Kappa statistic was used.

Results: The mean age of the study cohort was 56.30±11.42 years. A slight male preponderance (56%) was observed. With regards to mean of total CPB time, it was insignificantly higher in patients with adverse neurologic outcomes as compared to those without adverse neurological outcomes (165.83±53.61 minutes vs. 121.36±21.41 minutes; p-value=0.098). Patients with adverse neurologic outcomes had significantly higher ONSD (average of both planes) on CPB from 60 minutes through 150 minutes/end of CPB timeline for right eye (p-value < 0.001), left eye (p-value <0.001), and both eyes (p-value <0.001). For patients with ONSD value (average of both eyes in both planes of each eye) ≥5.5 mm had more likelihood to develop adverse neurologic outcomes, postoperatively. With respect to maximum ONSD anytime during CPB (average of both eyes in both planes of each eye), an arbitrary cut-off of ≥5.5 mm showed a sensitivity of 100%, specificity of 95%, diagnostic accuracy of 100%, and predictive value of 100% with significant p-value of <0.001.

Conclusion: Serial ultrasonographic ONSD measurement is assuredly a promising tool to monitor elevated level of ICP as well as a good predictor for the assessment of major adverse neurologic outcomes secondary to open heart cardiac surgeries.


Adverse neurological outcomes, Cardiopulmonary bypass, Intracranial pressure, Optic nerve sheath diameter

There are presently over 500 centres where approximately 60,000 open heart surgeries performed annually in India and the majority of surgeries are carried out for coronary artery disease and valvular heart disease (1). Over the last four decades, major technical breakthroughs in cardiac surgeries have resulted in a continuous decline in mortality and morbidity. Notwithstanding, neurological injury continues to be the leading source of postoperative morbidity and disability secondary to cardiac surgeries and also accounts for a growing percentage of perioperative mortality (2).

Since the advent of Cardiopulmonary Bypass (CPB) in the early 1950s, the neurological consequences of cardiac surgeries have been a prominent concern. As a matter of fact, a considerable proportion of patients experience a perioperative complication including complication of central nervous system. Adverse neurological outcomes following cardiac surgery may occur because of damage to the brain, spinal cord and/or peripheral nerves. These neurological injuries have a very wide range of manifestations from subtle changes in personality, behaviour and cognitive function to fatal brain injury, called the ‘Cerebral Catastrophe’. Cardiac surgeries have a formidable impact on the quality of social life and economic growth (3). Optic Nerve Sheath Diameter (ONSD) is being used as a non invasive method of measuring Intracranial Pressure (ICP) in an emergency setting in cases of severe head injury, cerebrovascular accident, meningoencephalitis and metabolic encephalopathy (4).

Quantification of ONSD is a promising and versatile method for detecting alterations in Intracranial Pressure (ICP). In fact, many recent studies have discovered a strong relationship between ONSD enlargement and elevated ICP (5),(6),(7). The parallel increase in the ONSD with ICP occurs owing to the fact that the optic nerve is in the direct continuity of brain (extension of white matter). Like the brain, the optic nerve is also surrounded by subarachnoid space and filled with cerebrospinal fluid. Whenever there is variation in ICP, there seems to be a transfer of pressure through the subarachnoid space (8). As far as we know, diverse methods have been used to measure ONSD comprising Magnetic Resonance Imaging (MRI), computed tomography and ultrasonography. However, due to the fact that retrobulbar optic space is full of soft tissues, values obtained from MRI are presumed as a gold standard (9).

It has been reported that the measurements taken by the transorbital ultrasonography have good agreement with the measurements acquired by 3 Tesla MRI. Moreover, ONSD measured by transbulbar ultrasonography appears to have high agreement with MRI along with ready availability, reproducibility, cost-effectiveness and a method that has low slope of learning (7).

What makes the present study novel is the fact that despite the best endeavours, no study could be found that investigated the role of serial ultrasonographic ONSD measurement, as a non invasive tool to monitor ICP in patients undergoing open heart surgery and predict adverse neurological outcomes postoperatively. This study aimed at making a humble attempt at evaluating the possibility of serial ultrasonographic ONSD measurements as a surrogate monitor of elevated ICP, and to correlate the same with adverse neurologic outcomes (if any), in the setting of open heart surgeries done under CPB.

Material and Methods

This was an open-label, prospective, observational study conducted in Department of Anaesthesia, Command Hospital, Karnataka, India, from June 2016 to July 2018. The study protocol was approved by the Institutional Ethics Committee (Reference no: CHAFB/1911/2/PG). Informed consent was obtained from each of the participants prior to enrolling.

Inclusion criteria: All consecutively patients aged between 15 and 80 years who underwent open heart cardiac surgeries irrespective of gender, primary diagnosis and preoperative American society of Anaesthesiologist’s Physical Status (ASA PS) grade were enrolled.

Exclusion criteria: All off-pump cardiac surgery, minimally invasive cardiac surgery irrespective of cardiopulmonary bypass, recent history of cerebrovascular accident or intracranial hypertension due to any cause, active ocular ailments confounding ONSD measurements, debilitating psychiatric illness precluding valid consent and/or assessment of neurologic status, and known allergy to ultrasound conductive gels were excluded from the study.


All enrolled patients were explained in detail about anaesthetic procedure on the day of the surgery. Preanaesthetic evaluation, appropriate laboratory, and radiological investigations were carried out.

Baseline neurological examinations such as higher mental functions, cranial, sensory and motor nerves examination, reflex-stone power, localizing signs, and any focal neurologic deficits were performed in each patient and duly recorded. All patients were kept Nil per Os (NPO) from 12 midnight to before surgery and had received ranitidine 150 mg tablet as pre medication unless contraindicated.

Importantly, peripheral oxygen saturation, blood pressure (systolic and diastolic mean arterial pressure), heart rate, core and peripheral temperature, end-tidal carbon dioxide concentration, central venous pressure, pulmonary artery wedge pressure (whenever applicable), 12 channel electrocardiogram were monitored throughout the cardiac surgery. Both eyelids closed with sterile transparent film and liberal use of ultrasound transmission jelly.

Surgical procedures were performed with the aid of a portable point of care ultrasound device (serial no: LW-62002685 z6 model by Mindray Medical International Ltd., Shenzhen, China) along with a 5-10 MHz (probe code 7L4P) linear ultrasound probe throughout the surgery. All observations were recorded by a single observer. After completion of the cardiac surgery, as a routine institutional cardiothoracic and vascular surgery (CTVS)/ Intensive Coronary Care Unit (ICCU) protocol, all patients were shifted to the ICCU for elective postoperative mechanical ventilation. The first assessment of readiness for extubation (i.e the first postoperative neurological assessment) was made at six hours, and then further recorded at 24 hours and after 7 days postoperatively.

After the surgery, the patients were stratified into the following two groups:

• Patients with adverse neurological outcomes
• Patients without adverse neurological outcomes

Optic Nerve Sheath Diameter (ONSD) measurement

After surgery, ONSD measurement was carried out in each patient. Ultrasonographically, ONSD was identified at a point 3 mm behind the point of entry of optic nerve into the globe, in both eyes, for each measurement. For each optic nerve, the four measurements were made in each instance: two in the sagittal plane and two in the transversal plane. The ultrasound probe was rotated clockwise while switching between measurements in the planes in order to maintain uniformity. The ONSD reading prior to induction (baseline) and immediately following endotracheal intubation were noted for both eyes in each patient. Then, serial ONSD measurements were made at 15 min intervals after the institution of CPB until the end of bypass. However, after 150 minutes of bypass time, only the last 15 minutes reading was recorded. Complete postoperative monitoring and management in each case were done as per institutional protocols by a multi-disciplinary team comprising various consultants, residents, nursing staff and paramedical staff of the hospital.

Statistical Analysis

Statistical analyses were done using the Statistical Package for Social Sciences (SPSS) version 18.0 software (SPSS Inc., Chicago, IL, USA) and R Environment version 3.2.2. Continuous variables were expressed as mean and standard deviation and were compared using the student t-tests. Chi-square or Fisher's-exact test (depending on sample size) was used to compare categorical variables that were presented as numbers and percentages. To assess inter-rater reliability for categorical variables, the Cohen’s Kappa statistic was used. The Kappa result was interpreted as follows:

• ≤ 0: no agreement
• 0.01-0.20: slight
• 0.21-0.40: fair
• 0.41-0.60 moderate
• 0.61-0.80 substantial
• 0.81-1.00 perfect agreement

The p-value of <0.05 was deemed as statistically significant.


A total of 50 patients, who underwent open heart surgery, were assessed. The mean age of the study cohort was 56.30±11.42 years. A slight male preponderance (56%) was noted. As demonstrated in (Table/Fig 1), a variety of primary diagnosis was associated with cardiac surgery, among them; triple vessel coronary artery disease (56%) was the most frequent primary diagnosis.

Distribution of surgical procedures among patients with and without adverse neurological outcome is demonstrated in (Table/Fig 2). Out of the total 50 patients, six patients (12%) had adverse neurological outcome postoperatively, of which, four patients (66.7%) had undergone Coronary Artery Bypass Graft Surgery (CABG), one (2%) had undergone double valve replacement and one patient (16.7%) had undergone mitral valve replacement (16.7%).

Of the total six patients with adverse neurologic outcomes, none of the patients was extubated at 6 hours postoperatively. One of the patients suffered from delayed extubation on day 3 postoperatively due to diffuse cerebral edema, which was likely on account of related hypoxic injury as evidenced on CT scan of the head. Nevertheless, this patient did not demonstrate any neurological deficits on discharge. Six patients (12%) with adverse outcomes were extubated beyond 24 hours postoperatively and developed various motor manifestations as enumerated in (Table/Fig 3). One of the patients died within the 7th day of surgery due to quadriparesis, multiple intercurrent and consequent complications.

Out of the 50 patients studied, patients who developed postoperative adverse neurologic outcomes were either ASA PS grade two (20%), three (66%) or four (2%) (Table/Fig 4).

The mean of total CPB time (in minutes) among patients with and without adverse neurological outcomes were compared, and obtained findings revealed that mean CPB time was higher in patients with adverse neurologic outcomes but the value was not significant (165.83±53.61 minutes vs. 121.36±21.41 minutes; p-value=0.098) (Table/Fig 5).

The ONSD values of the average of both planes (viz. sagittal and transverse) in right eye, left eye and both eyes in relation to adverse neurologic outcomes at each time point of measurement were compared. Patients with adverse neurological outcomes had significantly higher ONSD (average of both planes) on CPB from 60 minutes through 150 minutes/end of CPB timeline for right eye (p-value <0.001), left eye (p-value <0.001), and both eyes (p-value <0.001). (Table/Fig 6) demonstrating trend of mean optic nerve sheath diameter values of right eye, left eye and both eyes.

As illustrated in (Table/Fig 7), the maximum ONSD recorded anytime during CPB (average of both planes in both eyes) of ≥5.5 mm was appeared to be more likely to develop adverse neurologic outcomes postoperatively (100% vs. 4.5%, p-value <0.001). Comparison of consolidated validity measures such as sensitivity, specificity and diagnostic accuracy between maximum ONSD anytime during CPB and average ONSD of all values during CPB are compared in (Table/Fig 8). To measure “maximum ONSD anytime during CPB (average of both eyes in both planes of each eye)”, an arbitrary cut off of ≥5.5 mm demonstrated a sensitivity of 100%, specificity of 95%, diagnostic accuracy of 100%, and predictive value of negative test of 100% with significant p-value of <0.001.


Ultrasonographic ONSD measurement is a relatively recent application for the assessment of optic ultrasound. In the last few decades, it has been increasingly used as a surrogate marker for elevated ICP (10).

The utility of ultrasonographic ONSD measurement has been extensively evaluated in a variety of clinical, laboratory, imaging and critical care settings as a reliable tool to predict elevated ICP. Hamilton DR et al., from his preclinical study on a porcine model, asserted the utility of ONSD to non invasively validate acute changes in ICP over 1 hour. Furthermore, they advocated the implementation of this approach in humans using measurement of direct ICP, to prove its utility as a screening tool for acute and chronically enlarged diameters caused by elevated pressure in clinical settings (11). Širanovic´ M et al., presented correlation between ultrasonographic measurement of ONSD and direct measurement of ICP in patients with traumatic brain injury (12). Usefulness of ocular ultrasound scans in identifying elevated ICP was reported in diverse conditions. Geeraerts T et al., reported in severe traumatic brain injury, Hansen HC et al., in cerebrospinal fluid absorption disorders (communicating hydrocephalus or optic disc elevation of unknown origin), Baurele J et al., in idiopathic intracranial hypertension, Moretti R et al., in intracranial hemorrhage, Zaidi SJH et al., in ventriculoperitoneal shunt obstruction (6),(13),(14),(15),(16).

The mean age of the index study cohort was 56.30±11.42 years. Consistent with the literature, this analysis also showed advanced age as a robust predictor of neuropsychological injury secondary to cardiac (17),(18). In this study, six patients had adverse neurologic outcomes secondary to CABG surgery, which is consistent with the trend that most cases of adverse neurologic outcomes reported are of CABG. As such, it has been noted that the event of a clinically evident stroke secondary to CABG ranged from 0.8% to 5.2% (19). A German population-based study showed that the incidence of stroke increases by 3.3% when CABG is combined with valve replacement surgery (20). Moreover, another study claimed that the incidence of stroke increases further (up to 6.7%) in patients undergoing multiple valves replacement surgery (21). Literature regarding the relationship between duration of bypass and adverse neurologic outcomes are conflicting. In the present study, patients with adverse neurologic outcomes had higher mean CPB duration but the value was statistically insignificant (165.83±53.61 minutes vs. 121.36±21.41minutes). The institutional protocol routinely employs non pulsatile hypothermic CPB. Many authors have presented that progressive cerebral vasoconstriction can give rise to cerebral injury during prolonged non pulsatile hypothermic CPB as an additional responsible factor (22),(23), whilst others have disputed it [24,25].

There is a wide variation and a lack of consensus about the optimal cut-off values of ONSD and what measurement represents elevated ICP. Frumin E et al., measured ONSD of 24 patients in the supine position in correlation with ICP measured by external ventricular drain and concluded that the optimal ONSD for the elevated ICP of >20 mmHg was ≥5.2 mm with a sensitivity and specificity of 83.3% and 100%, respectively (26). Findings of a study published by Rajajee V et al., demonstrated that the best cut off value of ONSD was ≥0.48 cm, which was a good predictor of ICP >20 mmHg with sensitivity and specificity of 96% and 94%, respectively (27). Receiver Operating Characteristic Curve (ROC) analysis demonstrated that the best cut off for the detection of elevated ICP (> 20 mmHg) was 6.1 with a sensitivity of 100% and specificity of 83% in the study reported by Å iranović M et al., and 5.9 mm with a sensitivity of 95% and specificity of 79% by Geeraerts T et al., (6),(12). Recently, cut-off values for elevated ICP have been proposed to be 5 to 5.9 mm (28). This discordance in cut-off values may be attributable to multiple reasons, including the baseline variability. But in general, if we keep higher the sensitivity, the cut-off value comes down and similarly keeping the specificity higher then cut off value migrates towards the upper side. In the present study, maximum ONSD anytime during CPB with an arbitrary cut-off of 5.5 mm proved to be a significant parameter in predicting postoperative adverse neurologic outcomes; with a sensitivity of 100%, specificity of 95%, diagnostic accuracy of 100%, and negative predictive value of 100%.


The present study was mainly restricted by small sample size and short-term follow-up. Moreover, the data about the duration of cardiac disease, level of control of co-morbidities, intraoperative hemodynamic trends, CPB conduct modes and practices were not adequately recorded, and hence their bearing on postoperative neurologic outcomes could not be interpreted. Further studies with greater sample size, better power of estimate, longer follow up, ONSD acquisition, and the influence of co-morbidities are warranted to validate our arbitrary cut off of 5.5 mm.


It is concluded that the parameter maximum ONSD anytime during CPB (average of both eyes in both planes of each cycle) has a high sensitivity, specificity, diagnostic accuracy, as well as predictive value of negative test. Hence, it is a suitable candidate for the predictor of adverse postoperative neurologic outcomes following open heart cardiac surgeries done on CPB. It may further be stated that elevated ONSD on CPB beyond cut off serves to suggest instituting appropriate measures to reduce ICP in an attempt to halt anticipated ongoing neurologic damage and prompt further neuroimaging confirmatory modalities.


Das MK, Kumar S, Deb PK, Mishra S. History of cardiology in India. Elsevier; 2015. [crossref] [PubMed]
Mills SA. Cerebral injury and cardiac operations. Ann Cardiothorac Surg. 1993;56(5):S86-S91. [crossref]
Arrowsmith J, Grocott H, Reves J, Newman M. Central nervous system complications of cardiac surgery. Br J Anaesth. 2000;84(3):378-93. [crossref] [PubMed]
Shirodkar CG, Rao SM, Mutkule DP, Harde YR, Venkategowda PM, Mahesh MU. Optic nerve sheath diameter as a marker for evaluation and prognostication of intracranial pressure in Indian patients: An observational study. Indian J Crit Care Med. 2014;18(11):728. [crossref] [PubMed]
Geeraerts T, Newcombe VF, Coles JP, Abate MG, Perkes IE, Hutchinson PJ, et al. Use of T2-weighted magnetic resonance imaging of the optic nerve sheath to detect raised intracranial pressure. Crit Care. 2008;12(5):01-07. [crossref] [PubMed]
Geeraerts T, Merceron S, Benhamou D, Vigué B, Duranteau J. Noninvasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Crit Care. 2008;12(2):01-02. [crossref] [PubMed]
Bäuerle J, Schuchardt F, Schroeder L, Egger K, Weigel M, Harloff A. Reproducibility and accuracy of optic nerve sheath diameter assessment using ultrasound compared to magnetic resonance imaging. BMC Neurol. 2013;13(1):01-06. [crossref] [PubMed]
Killer H, Jaggi G, Flammer J, Miller N, Huber A. The optic nerve: a new window into cerebrospinal fluid composition? Brain. 2006;129(4):1027-30. [crossref] [PubMed]
Kalantari H, Jaiswal R, Bruck I, Matari H, Ghobadi F, Weedon J, et al. Correlation of optic nerve sheath diameter measurements by computed tomography and magnetic resonance imaging. Am J Emerg Med. 2013;31(11):1595-97. [crossref] [PubMed]
Steinborn M, Fiegler J, Ruedisser K, Hapfelmeier A, Denne C, Macdonald E, et al. Measurement of the optic nerve sheath diameter in children: comparison between transbulbar sonography and magnetic resonance imaging. Ultraschall Med. 2012;33(06):569-73. [crossref] [PubMed]
Hamilton DR, Sargsyan AE, Melton SL, Garcia KM, Oddo B, Kwon DS, et al. Sonography for determining the optic nerve sheath diameter with increasing intracranial pressure in a porcine model. J Med Ultrasound. 2011;30(5):651-9. [crossref] [PubMed]
Å iranović M, Magdić Turković T, Gopčević A, Kelević M, Kovač N, Kovač J, et al. Comparison of ultrasonographic measurement of optic nerve sheath diameter (ONSD) versus direct measurement of intracranial pressure (ICP) in traumatic brain injury patients. Signa Vitae. 2011;6(1):33-5. [crossref]
Hansen HC, Helmke K. Validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests. J Neurosurg. 1997;87(1):34-40. [crossref] [PubMed]
Bäuerle J, Nedelmann M. Sonographic assessment of the optic nerve sheath in idiopathic intracranial hypertension. J Neurol. 2011;258(11):2014-19. [crossref] [PubMed]
Moretti R, Pizzi B. Optic nerve ultrasound for detection of intracranial hypertension in intracranial hemorrhage patients: confirmation of previous findings in a different patient population. J Neurosurg Anesthesiol. 2009;21(1):16-20. [crossref] [PubMed]
Zaidi SJH, Yamamoto LG. Optic nerve sheath diameter measurements by CT scan in ventriculoperitoneal shunt obstruction. Hawaii J Health Soc Welf. 2014;73(8):251.
Newman MF, Kramer D, Croughwell ND, Sanderson I, Blumenthal JA, White WD, et al. Differential age effects of mean arterial pressure and rewarming on cognitive dysfunction after cardiac surgery. Anesth Analg. 1995;81(2):236-42. [crossref]
Tuman KJ, McCarthy RJ, Najafi H, Ivankovich AD. Differential effects of advanced age on neurologic and cardiac risks of coronary artery operations. J Thorac Cardiovasc Surg. 1992;104(6):1510-7. [crossref]
Breuer AC, Furlan AJ, Hanson MR, Lederman RJ, Loop FD, Cosgrove DM, et al. Central nervous system complications of coronary artery bypass graft surgery: prospective analysis of 421 patients. Stroke. 1983;14(5):682-7. [crossref] [PubMed]
Boeken U, Litmathe J, Feindt P, Gams E. Neurological complications after cardiac surgery: risk factors and correlation to the surgical procedure. The Thoracic and cardiovascular surgeon. 2005;53(01):33-36. [crossref] [PubMed]
Roselli EE, Pettersson GB, Blackstone EH, Brizzio ME, Houghtaling PL, Hauck R, et al. Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue. J Thorac Cardiovasc Surg. 2008;135(2):316-23. [crossref] [PubMed]
Prough DS, Rogers AT, Stump DA, Mills SA, Gravlee GP, Taylor C. Hypercarbia depresses cerebral oxygen consumption during cardiopulmonary bypass. Stroke. 1990;21(8):1162-6. [crossref] [PubMed]
Rogers A, Prough D, Stump D, Angert K, Butterworth J, Phipps J, et al. Hypercarbia depresses cerebral oxygen consumption during hypothermic cardiopulmonary bypass. Anesth Analg. 1988;67(2):187. [crossref]
Schell RM, Kern FH, Greeley WJ, Schulman SR, Frasco PE, Croughwell ND, et al. Cerebral blood flow and metabolism during cardiopulmonary bypass. Anesth Analg. 1993;76(4):849-65. [crossref] [PubMed]
Croughwell ND RJ, White WD, Grocott HP, Baldwin BI, Clements FM, Davis RD Jr, et al. Cardiopulmonary bypass time does not affect cerebral blood flow. Ann Thorac Surg. 1988;5(5):1226-30. [crossref]
Frumin E, Schlang J, Wiechmann W, Hata S, Rosen S, Anderson C, et al. Prospective analysis of single operator sonographic optic nerve sheath diameter measurement for diagnosis of elevated intracranial pressure. West J Emerg Med. 2014;15(2):217. [crossref] [PubMed]
Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL. Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocrit Care. 2011;15(3):506-15. [crossref] [PubMed]
Dubourg J, Javouhey E, Geeraerts T, Messerer M, Kassai B. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med. 2011;37(7):1059-68. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/55017.16501

Date of Submission: Jan 17, 2022
Date of Peer Review: Feb 23, 2022
Date of Acceptance: Mar 11, 2022
Date of Publishing: Jun 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Jan 18, 2022
• Manual Googling: Mar 02, 2022
• iThenticate Software: May 18, 2022 (24%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)