Assessment of brain midline shift using sonography in neurosurgical ICU patients

Introduction: Brain midline shift (MLS) is a life-threatening condition that requires urgent diagnosis and treatment. We aimed to validate bedside assessment of MLS with Transcranial Sonography (TCS) in neurosurgical ICU patients by comparing it to CT. Methods: In this prospective single centre study, patients who underwent a head CT were included and a concomitant TCS performed. TCS MLS was determined by measuring the difference between the distance from skull to the third ventricle on both sides, using a 2 to 4 MHz probe through the temporal window. CT MLS was measured as the difference between the ideal midline and the septum pellucidum. A significant MLS was defined on head CT as >0.5 cm. Results: A total of 52 neurosurgical ICU patients were included. The MLS (mean +/- SD) was 0.32 +/- 0.36 cm using TCS and 0.47 +/- 0.67 cm using CT. The Pearson's correlation coefficient (r(2)) between TCS and CT scan was 0.65 (P < 0.001). The bias was 0.09 cm and the limits of agreements were 1.10 and -0.92 cm. The area under the ROC curve for detecting a significant MLS with TCS was 0.86 (95% CI = 0.74 to 0.94), and, using 0.35 cm as a cut-off, the sensitivity was 84.2%, the specificity 84.8% and the positive likelihood ratio was 5.56. Conclusions: This study suggests that TCS could detect MLS with reasonable accuracy in neurosurgical ICU patients and that it could serve as a bedside tool to facilitate early diagnosis and treatment for patients with a significant intracranial mass effect.