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Modi P, Bhoi S, Aggarwal P, Nayer J, Sinha TP, Ekka M, Mishra PR, Kumar A, Pandey S. Feasibility of USG-Guided Objective Initial Assessment of Pupillary Size and Pupillary Reflexes Versus Clinical Examination in Patients With Altered Mental Status: A Cross-Sectional Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:335-346. [PMID: 37948504 DOI: 10.1002/jum.16366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/19/2023] [Accepted: 10/18/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Pupillary assessment is an important part of the neurological assessment which provides vital information in critically ill patients. However, clinical pupillary assessment is subjective. The ultrasound-guided pupillary examination is objective. There are limited pieces of literature regarding its use in assessing patients with altered mental status. So, we studied the extent of agreement of B-mode ultrasound with clinical examination for assessment of the pupillary size and reflex in patients with altered mental status. OBJECTIVES The primary objective was to determine the extent of agreement between clinical examination and ultrasound-based examination for assessing pupillary reflex and size in patients with altered mental status in two settings (trauma and non-trauma patients). METHODS Exactly 200 subjects (158 males, mean [range] age 43.56 [18-92 years]) with no history of partial globe rupture or dementia were included in this cross-sectional study from March 2019 to March 2020. B-mode ultrasound was performed with the subject's eyes closed using a 7-12 MHz linear probe and a standardized light stimulus. ICC score, paired t-test, kappa, Wilcoxon signed-rank test, and Bland-Altman plots were used for statistical analysis. RESULTS The clinical-USG agreement for pupillary light reflex examination (Pupillary Diameter [PD] at rest, after direct light stimulation [Dstim ] and consensual light stimulation [Cstim ]) was excellent (ICC, 0.93-0.96). The Kappa coefficient (0.74 ± 0.07) showed an agreement of 87.36% between clinical and USG examination for pupillary reflex (reactive or non-reactive). CONCLUSION USG-guided pupillary examination proves to be a better adjunct to neurological assessment in patients with altered mental status.
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Affiliation(s)
- Priyanka Modi
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | | | - Jamshed Nayer
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | | | - Meera Ekka
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | | | - Akshay Kumar
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | - Savan Pandey
- Department of Emergency Medicine, AIIMS, New Delhi, India
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Bhatt R, Khanna P. Role of Ultrasound in Neurocritical Care. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0040-1712069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractBedside point of care ultrasound has acquired an extremely significant role in diagnosis and management of neurocritical care, just as it has in other specialties. Easy availability and increasing expertise have allowed the intensivists to use it in a wide array of situations, such as confirming clinical findings as well as for interventional and prognostic purposes. At present, the clinical applications of ultrasonography (USG) in a neurosurgical patient include estimation of elevated intracranial pressure (ICP), assessment of cerebral blood flow (CBF) and velocities, diagnosis of intracranial mass lesion and midline shifts, and examination of pupils, apart from the systemic applications. Transcranial sonography has also found use in the diagnosis of the cerebral circulatory arrest. An increasing number of clinicians are now relying on the use of ultrasound in the neurointensive care unit for neurological as well as non-neurological indications. These uses include the diagnosis of shock, respiratory failure, deep vein thrombosis and performing bedside procedures.
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Affiliation(s)
- Rashmi Bhatt
- International Training Fellow, Aberdeen Royal Infirmary, Aberdeen, Scotland
| | - Puneet Khanna
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Walter U. From outer space to earth: Ultrasonographic dynamic pupillometry for autonomic testing and neuro-critical care. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:7-9. [PMID: 33530121 DOI: 10.1055/a-1256-4791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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Farina F, Vosko MR, Baracchini C, Ermani M, Sommer P, Greisenegger S, Laubichler P, Struhal W, Kellermair L, Ransmayr G, Brunner C. Ultrasound Examination of the Pupil - A New Tool for the Neuro-Ophthalmological Assessment. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:84-91. [PMID: 32688403 DOI: 10.1055/a-1208-1482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Pupil examination represents a diagnostic and prognostic test in the management of several neurological diseases. Infrared video pupillometry (IVP) is the gold standard, since it is not routinely available, a noninvasive bedside ultrasound assessment has been proposed as an alternative. The aim of this study was to assess the feasibility and reproducibility of ultrasound pupillometry (UP) in comparison with IVP. MATERIALS AND METHODS 81 subjects (43 men and 38 women, mean age: 52 ± 20 years and 49 ± 19 years, respectively) with no history of neurophthalmologic disease were enrolled. UP was performed with a 12-MHz linear probe according to current guidelines for orbital insonation. Light and painful stimuli were applied to test pupillary light reflex (PLR) and ciliospinal reflex (CR). In 30 of these subjects IVP examination was performed additionally to obtain intra-observer and inter-observer agreement. RESULTS Increasing age was associated with a decreased pupillary diameter (PD) at rest, after PLR and CR (R -0.728, p < 0.01, R -0.643, p < 0.01, R 0.674, p < 0.001 respectively), while no association was noticed with time to constriction/dilation. UP measurements were reproducible (rate of inter- and intra-observer agreement: R 0.979, p < 0.01, R 0.946, p < 0.01 respectively) and concordant with IVP (PLR R 0.831, p < 0.01; CR R 0.879, p < 0.01). CONCLUSION According to our study, ultrasound pupillometry is a feasible and reliable technique for bedside pupillary function assessment, and is a good alternative to infrared video pupillometry. Moreover, it represents the only way for functional pupillary assessment in patients with periorbital hematoma.
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Affiliation(s)
- Filippo Farina
- Department of Neuroscience, University of Padua School of Medicine, Stroke Unit and Neurosonology Laboratory, Padova, Italy
| | - Milan R Vosko
- Department of Neurology 2, Kepler Universitätsklinikum, Med Campus III, Stroke Unit and Neurosonology Laboratory, Linz, Austria
| | - Claudio Baracchini
- Department of Neuroscience, University of Padua School of Medicine, Stroke Unit and Neurosonology Laboratory, Padova, Italy
| | - Mario Ermani
- Department of Neuroscience, University of Padua School of Medicine, Neurological Clinic, Padova, Italy
| | - Peter Sommer
- Department of Neurology, Krankenanstalt Rudolfstiftung Vienna, Austria
| | | | - Peter Laubichler
- Department of Ophtalomology and Optometry, Kepler University Hospital GmbH, Johannes Kepler University Linz, Austria
| | - Walter Struhal
- Department of Neurology, University Clinic Tulln, Karl Landsteiner University of Health Sciences, Site Tulln, Austria
| | - Lukas Kellermair
- Department of Neurology 2, Kepler Universitätsklinikum, Med Campus III, Stroke Unit and Neurosonology Laboratory, Linz, Austria
| | - Gerhard Ransmayr
- Department of Neurology 2, Kepler Universitätsklinikum, Med Campus III, Stroke Unit and Neurosonology Laboratory, Linz, Austria
| | - Cornelia Brunner
- Department of Neurology, University Clinic Tulln, Karl Landsteiner University of Health Sciences, Site Tulln, Austria
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Yu J, Yoon H, Khalifa YM, Emelianov SY. Design of a Volumetric Imaging Sequence Using a Vantage-256 Ultrasound Research Platform Multiplexed With a 1024-Element Fully Sampled Matrix Array. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2020; 67:248-257. [PMID: 31545718 PMCID: PMC7008949 DOI: 10.1109/tuffc.2019.2942557] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Ultrasound imaging using a matrix array allows real-time multi-planar volumetric imaging. To enhance image quality, the matrix array should provide fast volumetric ultrasound imaging with spatially consistent focusing in the lateral and elevational directions. However, because of the significantly increased data size, dealing with massive and continuous data acquisition is a significant challenge. We have designed an imaging acquisition sequence that handles volumetric data efficiently using a single 256-channel Verasonics ultrasound research platform multiplexed with a 1024-element matrix array. The developed sequence has been applied for building an ultrasonic pupilometer. Our results demonstrate the capability of the developed approach for structural visualization of an ex vivo porcine eye and the temporal response of the modeled eye pupil with moving iris at the volume rate of 30 Hz. Our study provides a fundamental ground for researchers to establish their own volumetric ultrasound imaging platform and could stimulate the development of new volumetric ultrasound approaches and applications.
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Modi P, Bhoi S, Aggarwal P, Murmu LR, Sinha TP, Ekka M, Kumar A, Jamshed N. The changing paradigm from subjectivity to objectivity in pupillary assessment during neurological examination. Am J Emerg Med 2019; 37:1594-1595. [PMID: 30712949 DOI: 10.1016/j.ajem.2019.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/20/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Priyanka Modi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPN Apex Trauma centre, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - L R Murmu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Tej Prakash Sinha
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Meera Ekka
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | - Akshay Kumar
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, AIIMS, New Delhi, India
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Skrzypiec-Spring M, Haczkiewicz K, Sapa A, Piasecki T, Kwiatkowska J, Ceremuga I, Wozniak M, Biczysko W, Kobierzycki C, Dziegiel P, Podhorska-Okolow M, Szelag A. Carvedilol Inhibits Matrix Metalloproteinase-2 Activation in Experimental Autoimmune Myocarditis: Possibilities of Cardioprotective Application. J Cardiovasc Pharmacol Ther 2017; 23:89-97. [PMID: 28854816 DOI: 10.1177/1074248417725058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIMS Acute myocarditis is a potentially lethal inflammatory heart disease that frequently precedes the development of dilated cardiomyopathy and subsequent heart failure. At present, there is no effective standardized therapy for acute myocarditis, besides the optimal care of heart failure and arrhythmias in accordance with evidence-based guidelines and specific etiology-driven therapy for infectious myocarditis. Carvedilol has been shown to be cardioprotective by reducing cardiac pro-inflammatory cytokines present in oxidative stress in certain heart diseases. However, effects of carvedilol administration in acute myocarditis with its impact on matrix metalloproteinases' (MMPs) activation have not been elucidated. METHODS AND RESULTS Carvedilol in 3 doses (2, 10, and 30 mg/kg) was given daily to 3 study groups of rats (n = 8) with experimental autoimmune myocarditis by gastric gavage for 3 weeks. In comparison to untreated rats (n = 8) with induced myocarditis, carvedilol significantly prevented the left ventricle enlargement and/or systolic dysfunction depending on the dose in study groups. Performed zymography showed enhanced MMP-2 activity in untreated rats, while carvedilol administration reduced alterations. This was accompanied by prevention of troponin I release and myofilaments degradation in cardiac muscle tissue. Additionally, severe inflammatory cell infiltration was detected in the nontreated group. Carvedilol in all doses tested, had no impact on severity of inflammation. The severity of inflammation did not differ between study groups and in relation to the untreated group. CONCLUSIONS The protective effects of carvedilol on heart function observed in the acute phase of experimental autoimmune myocarditis seem to be associated with its ability to decrease MMP-2 activity and subsequently prevent degradation of myofilaments and release of troponin I while not related to suppression of inflammation.
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Affiliation(s)
| | - Katarzyna Haczkiewicz
- 2 Department of Histology and Embryology, Wroclaw Medical University, Wroclaw, Poland
| | - Agnieszka Sapa
- 3 Department of Medical Laboratory Diagnostics, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Piasecki
- 4 Department of Epizootiology and Clinic of Bird and Exotic Animals, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Joanna Kwiatkowska
- 1 Department of Pharmacology, Wroclaw Medical University, Wroclaw, Poland
| | - Ireneusz Ceremuga
- 5 Department of Medical Biochemistry, Wroclaw Medical University, Wroclaw, Poland
| | - Mieczyslaw Wozniak
- 3 Department of Medical Laboratory Diagnostics, Wroclaw Medical University, Wroclaw, Poland
| | - Wieslawa Biczysko
- 6 Department of Clinical Pathomorphology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Piotr Dziegiel
- 2 Department of Histology and Embryology, Wroclaw Medical University, Wroclaw, Poland.,7 Department of Physiotherapy, University School of Physical Education, Wroclaw, Poland
| | | | - Adam Szelag
- 1 Department of Pharmacology, Wroclaw Medical University, Wroclaw, Poland
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Farina F, Brunner C, Schreiber SJ, Palmieri A, Struhal W, Baracchini C, Vosko MR. Ultrasound examination of the pupil suggestive for carotid dissection. Neurology 2017; 89:973-974. [DOI: 10.1212/wnl.0000000000004299] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Invasive and ultrasound based monitoring of the intracranial pressure in an experimental model of epidural hematoma progressing towards brain tamponade on rabbits. ScientificWorldJournal 2014; 2014:504248. [PMID: 24578637 PMCID: PMC3918727 DOI: 10.1155/2014/504248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 11/12/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION An experimental epidural hematoma model was used to study the relation of ultrasound indices, namely, transcranial color-coded-Doppler (TCCD) derived pulsatility index (PI), optic nerve sheath diameter (ONSD), and pupil constriction velocity (V) which was derived from a consensual sonographic pupillary light reflex (PLR) test with invasive intracranial pressure (ICP) measurements. MATERIAL AND METHODS Twenty rabbits participated in the study. An intraparenchymal ICP catheter and a 5F Swan-Ganz catheter (SG) for the hematoma reproduction were used. We successively introduced 0.1 mL increments of autologous blood into the SG until the Cushing reaction occurred. Synchronous ICP and ultrasound measurements were performed accordingly. RESULTS A constant increase of PI and ONSD and a decrease of V values were observed with increased ICP values. The relationship between the ultrasound variables and ICP was exponential; thus curved prediction equations of ICP were used. PI, ONSD, and V were significantly correlated with ICP (r² = 0.84 ± 0.076, r² = 0.62 ± 0.119, and r² = 0.78 ± 0.09, resp. (all P < 0.001)). CONCLUSION Although statistically significant prediction models of ICP were derived from ultrasound indices, the exponential relationship between the parameters underpins that results should be interpreted with caution and in the current experimental context.
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Ultrasound for the anesthesiologists: present and future. ScientificWorldJournal 2013; 2013:683685. [PMID: 24348179 PMCID: PMC3856172 DOI: 10.1155/2013/683685] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 09/26/2013] [Indexed: 12/13/2022] Open
Abstract
Ultrasound is a safe, portable, relatively inexpensive, and easily accessible imaging modality, making it a useful diagnostic and monitoring tool in medicine. Anesthesiologists encounter a variety of emergent situations and may benefit from the application of such a rapid and accurate diagnostic tool in their routine practice. This paper reviews current and potential applications of ultrasound in anesthesiology in order to encourage anesthesiologists to learn and use this useful tool as an adjunct to physical examination. Ultrasound-guided peripheral nerve blockade and vascular access represent the most popular ultrasound applications in anesthesiology. Ultrasound has recently started to substitute for CT scans and fluoroscopy in many pain treatment procedures. Although the application of airway ultrasound is still limited, it has a promising future. Lung ultrasound is a well-established field in point-of-care medicine, and it could have a great impact if utilized in our ORs, as it may help in rapid and accurate diagnosis in many emergent situations. Optic nerve sheath diameter (ONSD) measurement and transcranial color coded duplex (TCCD) are relatively new neuroimaging modalities, which assess intracranial pressure and cerebral blood flow. Gastric ultrasound can be used for assessment of gastric content and diagnosis of full stomach. Focused transthoracic (TTE) and transesophageal (TEE) echocardiography facilitate the assessment of left and right ventricular function, cardiac valve abnormalities, and volume status as well as guiding cardiac resuscitation. Thus, there are multiple potential areas where ultrasound can play a significant role in guiding otherwise blind and invasive interventions, diagnosing critical conditions, and assessing for possible anatomic variations that may lead to plan modification. We suggest that ultrasound training should be part of any anesthesiology training program curriculum.
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