Optic nerve sheath diameter (ONSD) ultrasound is becoming increasingly more popular for estimating raised intracranial pressure (ICP). We performed a systematic review and analysis of the diagnostic accuracy of ONSD when compared to the standard invasive ICP measurement.MethodWe performed a systematic search of PUBMED and EMBASE for studies including adult patients with suspected elevated ICP and comparing sonographic ONSD measurement to a standard invasive method. Quality of studies was assessed using the QUADAS‐2 tool by two independent authors. We used a bivariate model of random effects to summarize pooled sensitivity, specificity, and diagnostic odds ratio (DOR). Heterogeneity was investigated by meta‐regression and sub‐group analyses.ResultsWe included 18 prospective studies (16 studies including 619 patients for primary outcome). Only one study was of low quality, and there was no apparent publication bias. Pooled sensitivity was 0.9 [95% confidence intervals (CI): 0.85–0.94], specificity was 0.85 (95% CI: 0.8–0.89), and DOR was 46.7 (95% CI: 26.2–83.2) with partial evidence of heterogeneity. The Area‐Under‐the‐Curve of the summary Receiver‐Operator‐Curve was 0.93 (95% CI: 0.91–0.95, P < .05). No covariates were significant in the meta‐regression. Subgroup analysis of severe traumatic brain injury and parenchymal ICP found no heterogeneity. ICP and ONSD had a correlation coefficient of 0.7 (95% CI: 0.63–0.76, P < .05).ConclusionONSD is a useful adjunct in ICP evaluation but is currently not a replacement for invasive methods where they are feasible.