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Haberl H, Unterberg M, Adamzik M, Hagedorn A, Wolf A. [Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 1 - Primary Treatment Strategies, Haemodynamic Management and Multimodal Monitoring]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:450-465. [PMID: 39074790 DOI: 10.1055/a-2075-9351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.
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Sabater-Gárriz Á, Molina-Mula J, Montoya P, Riquelme I. Pain assessment tools in adults with communication disorders: systematic review and meta-analysis. BMC Neurol 2024; 24:66. [PMID: 38368314 PMCID: PMC10873938 DOI: 10.1186/s12883-024-03539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/15/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Verbal communication is the "gold standard" for assessing pain. Consequently, individuals with communication disorders are particularly vulnerable to incomplete pain management. This review aims at identifying the current pain assessment instruments for adult patients with communication disorders. METHODS A systematic review with meta-analysis was conducted on PubMed, PEDRO, EBSCOhost, VHL and Cochrane databases from 2011 to 2023 using MeSH terms "pain assessment, "nonverbal communication" and "communication disorders" in conjunction with additional inclusion criteria: studies limited to humans, interventions involving adult patients, and empirical investigations. RESULTS Fifty articles were included in the review. Seven studies report sufficient data to perform the meta-analysis. Observational scales are the most common instruments to evaluate pain in individuals with communication disorders followed by physiological measures and facial recognition systems. While most pain assessments rely on observational scales, current evidence does not strongly endorse one scale over others for clinical practice. However, specific observational scales appear to be particularly suitable for identifying pain during certain potentially painful procedures, such as suctioning and mobilization, in these populations. Additionally, specific observational scales appear to be well-suited for certain conditions, such as mechanically ventilated patients. CONCLUSIONS While observational scales dominate pain assessment, no universal tool exists for adults with communication disorders. Specific scales exhibit promise for distinct populations, yet the diverse landscape of tools hampers a one-size-fits-all solution. Crucially, further high-quality research, offering quantitative data like reliability findings, is needed to identify optimal tools for various contexts. Clinicians should be informed to select tools judiciously, recognizing the nuanced appropriateness of each in diverse clinical situations. TRIAL REGISTRATION This systematic review is registered in PROSPERO (International prospective register of systematic reviews) with the ID: CRD42022323655 .
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Affiliation(s)
- Álvaro Sabater-Gárriz
- Balearic ASPACE Foundation, Marratxí, Spain
- Department of Nursing and Physiotherapy, University of Balearic Islands, Palma, 07122, Spain
- Research Institute on Health Sciences (IUNICS), University of the Balearic Islands, Palma, 07122, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, 07010, Spain
| | - Jesús Molina-Mula
- Department of Nursing and Physiotherapy, University of Balearic Islands, Palma, 07122, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, 07010, Spain
| | - Pedro Montoya
- Research Institute on Health Sciences (IUNICS), University of the Balearic Islands, Palma, 07122, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, 07010, Spain
| | - Inmaculada Riquelme
- Department of Nursing and Physiotherapy, University of Balearic Islands, Palma, 07122, Spain.
- Research Institute on Health Sciences (IUNICS), University of the Balearic Islands, Palma, 07122, Spain.
- Health Research Institute of the Balearic Islands (IdISBa), Palma, 07010, Spain.
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3
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Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med 2022; 48:649-666. [PMID: 35595999 DOI: 10.1007/s00134-022-06702-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/09/2022] [Indexed: 01/04/2023]
Abstract
Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical management and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit.
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Tran DK, Poole C, Tobias E, Moores L, Espinoza M, Chen JW. 7- year Experience with Automated Pupillometry and Direct Integration with the Hospital Electronic Medical Record. World Neurosurg 2022; 160:e344-e352. [PMID: 35026454 DOI: 10.1016/j.wneu.2022.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Manual pupillary assessments are an integral part of the neurological evaluation in critically ill patients. Automated pupillometry provides reliable, consistent, and accurate measurement of the light response. We established a computer interface that allow for direct download of pupillometer information to our hospital EMR. Here, we report the single center experience. METHODS An interface allowing direct download of pupillometer data to our EMR was developed. We then performed a prospective study using an electronic survey distributed to nurse that used pupillometers in 2015, 2018, and 2020 using a 5-point Likert style format to evaluate the acceptance of this implementation. RESULTS In 2015, 22 nurses were surveyed with 50% of the respondents citing lack of pupillometers and 41% citing the labor intensity associated with data entry as the reason for the reluctance to use the pupillometer. The number of nurse responses in 2018 increased to 123 with 78% of nurses finding that the direct download to hospital EMR improved the efficiency of their neurological exams. In 2020, 108 nurses responded with similar responses to those in 2018. We added 3 additional questions regarding utility of the pupillometer during the COVID19 pandemic. 58% of nurses were reassured of the neurologic exam when using the pupillometer in lieu of a full exam to limit infectious exposure. CONCLUSIONS This is the first report of the implementation of a direct interface to download pupillometer data to the EMR. The positive effect on nursing workflow and documentation of pupillary findings is discussed.
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Affiliation(s)
- Diem Kieu Tran
- University of California, Department of Neurological Surgery, Orange, CA.
| | - Cassie Poole
- University of California, Department of Neurological Surgery, Orange, CA
| | - Evan Tobias
- University of California, Department of Informatics, Orange, CA
| | - Lisa Moores
- University of California, Department of Nursing, Orange, CA
| | | | - Jefferson W Chen
- University of California, Department of Neurological Surgery, Orange, CA
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Zhang H, Xu J, Yang X, Zou X, Shu H, Liu Z, Shang Y. Narrative Review of Neurologic Complications in Adults on ECMO: Prevalence, Risks, Outcomes, and Prevention Strategies. Front Med (Lausanne) 2021; 8:713333. [PMID: 34660625 PMCID: PMC8513760 DOI: 10.3389/fmed.2021.713333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/02/2021] [Indexed: 01/18/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.
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Affiliation(s)
- Hongling Zhang
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Ansari AS, Vehof J, Hammond CJ, Bremner FD, Williams KM. Evidence That Pupil Size and Reactivity Are Determined More by Your Parents Than by Your Environment. Front Neurol 2021; 12:651755. [PMID: 34012416 PMCID: PMC8127779 DOI: 10.3389/fneur.2021.651755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/29/2021] [Indexed: 01/19/2023] Open
Abstract
Purpose: A classic twin study to evaluate the relative contributions of genetic and environmental factors to resting pupil size and reactivity. Methods: Pupillometry was performed on 326 female twins (mean age 64 years) from the TwinsUK Adult Twin Registry, assessing resting pupil diameter in darkness and increasing levels of ambient light, alongside dynamic pupillary characteristics. Maximum-likelihood structural equation models estimated the proportion of trait variance attributable to genetic factors. Results: Mean (SD) pupil diameter in darkness was 5.29 mm (0.81), decreasing to 3.24 mm (0.57) in bright light. Pupil light reaction (PLR) had a mean (SD) amplitude of 1.38 mm (0.27) and latency of 250.34 milliseconds (28.58). Pupil size and PLR were not associated with iris colour, intraocular pressure or refractive error, but were associated with age (diameter β = -0.02, p = 0.016, constriction amplitude β = -0.01, p < 0.001, velocity β = 0.03, p < 0.001, and latency β = 0.98, p < 0.001). In darkness the resting pupil size showed a MZ intraclass correlation coefficient of 0.85, almost double that of DZ (0.44), suggesting strong additive genetic effects, with the most parsimonious model estimating a heritability of 86% [95% confidence interval (CI) 79-90%] with 14% (95% CI 10-21%) explained by unique environmental factors. PLR amplitude, latency and constriction velocity had estimated heritabilities of 69% (95% CI 54-79%), 40% (95% CI 21-56%), and 64% (95% CI 48-75%), respectively. Conclusion: Genetic effects are key determinants of resting pupil size and reactivity. Future studies to identify these genetic factors could improve our understanding of variation in pupil size and pupillary reactions in health and disease.
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Affiliation(s)
- Abdus Samad Ansari
- Section of Academic Ophthalmology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Jelle Vehof
- Section of Academic Ophthalmology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
- Department of Ophthalmology and Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Christopher J. Hammond
- Section of Academic Ophthalmology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Fion D. Bremner
- Department of Neuro-Ophthalmology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Katie M. Williams
- Section of Academic Ophthalmology, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
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Oshorov AV, Alexandrova EV, Muradyan KR, Sosnovskaya OY, Sokolova EY, Savin IA. [Pupillometry as a method for monitoring of pupillary light reflex in ICU patients]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:117-123. [PMID: 34156213 DOI: 10.17116/neiro202185031117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This review is devoted to the modern method of monitoring of pupil diameter and reactivity in patients with acute brain injury. The authors present complete data on diagnostic and prognostic capabilities of automated infrared pupillometry, which should take its rightful place in comprehensive assessment of functional brain state in ICU patients. In authors' opinion, clinical introduction of pupillometry will improve prediction of outcomes following acute brain injury and quality of neurological monitoring in patients with cerebral edema and intracranial hypertension.
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Affiliation(s)
- A V Oshorov
- Burdenko Center of Neurosurgery, Moscow, Russia
| | | | | | | | | | - I A Savin
- Burdenko Center of Neurosurgery, Moscow, Russia
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Automated Pupillometry Using a Prototype Binocular Optical Coherence Tomography System. Am J Ophthalmol 2020; 214:21-31. [PMID: 32114180 DOI: 10.1016/j.ajo.2020.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/07/2020] [Accepted: 02/13/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the test-retest reliability and diagnostic accuracy of a binocular optical coherence tomography (OCT) prototype (Envision Diagnostics, El Segundo, California, USA) for pupillometry. DESIGN Assessment of diagnostic reliability and accuracy. METHODS Fifty participants with relative afferent pupillary defects (RAPDs) confirmed using the swinging flashlight method (mean age 49.6 years) and 50 healthy control subjects (mean age 31.3 years) were examined. Participants twice underwent an automated pupillometry examination using a binocular OCT system that presents a stimulus and simultaneously captures OCT images of the iris-pupil plane of both eyes. Participants underwent a single examination on the RAPDx (Konan Medical, Irvine, California, USA), an automated infrared pupillometer. Pupil parameters including maximum and minimum diameter, and anisocoria were measured. The magnitude of RAPD was calculated using the log of the ratio of the constriction amplitude between the eyes. A pathological RAPD was above ±0.5 log units on both devices. RESULTS The intraclass correlation coefficient was >0.90 for OCT-derived maximum pupil diameter, minimum pupil diameter, and anisocoria. The RAPDx had a sensitivity of 82% and a specificity of 94% for detection of RAPD whereas the binocular OCT had a sensitivity of 74% and specificity of 86%. The diagnostic accuracy of the RAPDx and binocular OCT was 88% (95% confidence interval 80%-94%) and 80% (95% confidence interval 71%-87%) respectively. CONCLUSIONS Binocular OCT-derived pupil parameters had excellent test-retest reliability. The diagnostic accuracy of RAPD was inferior to the RAPDx and is likely related to factors such as eye movement during OCT capture. As OCT becomes ubiquitous, OCT-derived measurements may provide an efficient method of objectively quantifying the pupil responses.
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Tamura T, Namiki J, Sugawara Y, Sekine K, Yo K, Kanaya T, Yokobori S, Abe T, Yokota H, Sasaki J. Early outcome prediction with quantitative pupillary response parameters after out-of-hospital cardiac arrest: A multicenter prospective observational study. PLoS One 2020; 15:e0228224. [PMID: 32191709 PMCID: PMC7082023 DOI: 10.1371/journal.pone.0228224] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/09/2020] [Indexed: 11/18/2022] Open
Abstract
We aimed to determine the characteristics of quantitative pupillary response parameters other than amplitude of pupillary light reflex (PLR) early after return of spontaneous circulation (ROSC) and their implications for predicting neurological outcomes early after cardiac arrest (CA). Fifty adults resuscitated after non-traumatic out-of-hospital CA from four emergency hospitals were enrolled. Pupil diameters, PLR, constriction velocity (CV), maximum CV (MCV), dilation velocity (DV), latency of constriction, and Neurological Pupil index (NPi) were quantitatively measured at 0, 6, 12, 24, 48, and 72 h post-ROSC using an automated pupillometer. Change over time of each parameter was compared between favorable (Cerebral Performance Category [CPC] 1 or 2) and unfavorable neurological outcome (CPC 3–5) groups. Prognostic values of 90-day favorable outcome by these parameters and when combined with clinical predictors (witness status, bystander cardiopulmonary resuscitation, initial shockable rhythm, implementation of target temperature management) were tested. Thirteen patients achieved favorable outcome. CV, MCV, DV (P < 0.001), and NPi (P = 0.005) were consistently greater in the favorable group than in the unfavorable outcome group. Change over time was not statistically different between the groups in all parameters. CV, MCV, DV (ρ = 0.96 to 0.97, P < 0.001, respectively), and NPi (ρ = 0.65, P < 0.001) positively correlated with PLR. The prognostic value of 0-hour CV (area under the curve, AUC [95% confidence interval]: 0.92 [0.80–1.00]), DV (0.84 [0.68–0.99]), and NPi (0.88 [0.74–1.00]) was equivalent to that of PLR (0.84 [0.69–0.98]). Prognostic values improved to AUC of 0.95–0.96 when 0-hour PLR, CV, DV, or NPi was combined with clinical predictors. The 0-hour CV, MCV, and NPi showed equivalent prognostic values to PLR alone/in combination with clinical predictors. Using PLR among several quantitative pupillary response parameters for early neurological prognostication of post-CA patients is a simple and effective strategy.
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Affiliation(s)
- Tomoyoshi Tamura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jun Namiki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
- Department of Emergency Medicine, KKR Tachikawa Hospital, Tokyo, Japan
- * E-mail:
| | - Yoko Sugawara
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kikuo Yo
- Department of Emergency and Critical Care Medicine, Hiratsuka City Hospital, Kanagawa, Japan
| | - Takahiro Kanaya
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takayuki Abe
- Clinical and Translational Research Center, Keio University, Tokyo, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
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Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol 2019; 10:1261. [PMID: 32038449 PMCID: PMC6988791 DOI: 10.3389/fneur.2019.01261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/13/2019] [Indexed: 02/04/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Improved methods of monitoring real-time cerebral physiology are needed to better understand when secondary brain injury develops and what treatment strategies may alleviate or prevent such injury. In this review, we discuss emerging technologies that exist to better understand intracranial pressure (ICP), cerebral blood flow, metabolism, oxygenation and electrical activity. We also discuss approaches to integrating these data as part of a multimodality monitoring strategy to improve patient care.
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Affiliation(s)
- Brian Appavu
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - Brian T Burrows
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Stephen Foldes
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
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11
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Tekin K, Sekeroglu MA, Kiziltoprak H, Doguizi S, Inanc M, Yilmazbas P. Static and dynamic pupillometry data of healthy individuals. Clin Exp Optom 2018; 101:659-665. [PMID: 29356077 DOI: 10.1111/cxo.12659] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 12/17/2017] [Accepted: 12/18/2017] [Indexed: 08/30/2023] Open
Affiliation(s)
- Kemal Tekin
- Ophthalmology Department, Kars State Hospital, Kars, Turkey,
| | - Mehmet Ali Sekeroglu
- Ophthalmology Department, Ankara Ulucanlar Eye Training and Research Hospital, Ankara, Turkey,
| | - Hasan Kiziltoprak
- Ophthalmology Department, Ankara Ulucanlar Eye Training and Research Hospital, Ankara, Turkey,
| | - Sibel Doguizi
- Ophthalmology Department, Ankara Ulucanlar Eye Training and Research Hospital, Ankara, Turkey,
| | - Merve Inanc
- Ophthalmology Department, Ankara Ulucanlar Eye Training and Research Hospital, Ankara, Turkey,
| | - Pelin Yilmazbas
- Ophthalmology Department, Ankara Ulucanlar Eye Training and Research Hospital, Ankara, Turkey,
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Noninvasive Neuromonitoring: Current Utility in Subarachnoid Hemorrhage, Traumatic Brain Injury, and Stroke. Neurocrit Care 2018; 27:122-140. [PMID: 28004334 DOI: 10.1007/s12028-016-0361-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Noninvasive neuromonitoring is increasingly being used to monitor the course of primary brain injury and limit secondary brain damage of patients in the neurocritical care unit. Proposed advantages over invasive neuromonitoring methods include a lower risk of infection and bleeding, no need for surgical installation, mobility and portability of some devices, and safety. The question, however, is whether noninvasive neuromonitoring is practical and trustworthy enough already. We searched the recent literature and reviewed English-language studies on noninvasive neuromonitoring in subarachnoid hemorrhage, traumatic brain injury, and ischemic and hemorrhagic stroke between the years 2010 and 2015. We found 88 studies that were eligible for review including the methods transcranial ultrasound, electroencephalography, evoked potentials, near-infrared spectroscopy, bispectral index, and pupillometry. Noninvasive neuromonitoring cannot yet completely replace invasive methods in most situations, but has great potential being complementarily integrated into multimodality monitoring, for guiding management, and for limiting the use of invasive devices and in-hospital transports for imaging.
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Kim TJ, Ko SB. Implication of Neurological Pupil Index for Monitoring of Brain Edema. Acute Crit Care 2018; 33:57-60. [PMID: 31723862 PMCID: PMC6849000 DOI: 10.4266/acc.2017.00213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 06/02/2017] [Accepted: 06/04/2017] [Indexed: 01/20/2023] Open
Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.,Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.,Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
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Solari D, Miroz JP, Oddo M. Opening a Window to the Injured Brain: Non-invasive Neuromonitoring with Quantitative Pupillometry. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [DOI: 10.1007/978-3-319-73670-9_38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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15
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Bak E, Yoo YJ, Yang HK, Hwang JM. Quantitative Pupillometry of the Pupillary Light Reflex in Koreans. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2017. [DOI: 10.3341/jkos.2017.58.6.712] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Eunoo Bak
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yung Ju Yoo
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hee Kyung Yang
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jeong-Min Hwang
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Glaser J, Vasquez M, Cardarelli C, Galvagno S, Stein D, Murthi S, Scalea T. Through the looking glass: early non-invasive imaging in TBI predicts the need for interventions. Trauma Surg Acute Care Open 2016; 1:e000019. [PMID: 29766062 PMCID: PMC5891716 DOI: 10.1136/tsaco-2016-000019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 08/21/2016] [Accepted: 09/07/2016] [Indexed: 12/02/2022] Open
Abstract
Background Early diagnosis and treatment of traumatic brain injury (TBI) lead to better outcomes. It is difficult to predict which patients benefit from specialised centres, leading to over triage or delay in definitive care. We propose that a non-invasive test comprising optic nerve sheath ultrasound, transcranial Doppler and quantitative papillary reactivity is feasible, correlates with CT findings and may allow for accurate early identification of TBI. Methods A 1-year, prospective observation study evaluated a low-risk, non-invasive method of assessing brain injury. Patients underwent a non-invasive neurological examination for trauma, including the above assessments. Data from the three examinations were collected within 6 hours of injury and at 24 hours, and were analysed. Demographics, haemodynamic data, imaging results and short-term outcomes/interventions were recorded. Results Trauma patients over the age of 18 years, with a Glascow coma scale (GCS) of <12 or CT evidence of TBI, and intubated were included (N=100). These were divided into +CT (n=49) and −CT groups (n=51) according to the Marshall CT classification of TBI. The +CT group was older, with worse GCS and higher lactate (p=0.008, p=0.001 and p=0.01) but were otherwise well matched. The +CT group included all TBI types, with 96% of the patients having more than one type of TBI. Pulsatility index and neurologic pupillary index were predictive of a +CT (p=0.04, p=0.02). Area under the receiver-operating curve for the logistic regression model for the prediction of positive radiographic findings was r=0.718. Finally, we suggest a preliminary scoring heuristic for predicting a positive radiological finding in a patient with TBI. Conclusions The proposed examination is a feasible, non-invasive tool that may have clinical utility in the early prediction of TBI. If validated, it may improve trauma triage for the brain-injured patient. Further studies are warranted to validate this model.
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Affiliation(s)
- Jacob Glaser
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Matthew Vasquez
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Samuel Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Deborah Stein
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Sarah Murthi
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Thomas Scalea
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
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Yilmaz I, Faiz M, Saracoglu B, Yazici AT. Changes in Pupil Size Following Panretinal and Focal/Grid Retinal Photocoagulation: Automatic Infrared Pupillometry Study. J Ocul Pharmacol Ther 2015; 32:172-7. [PMID: 26580579 DOI: 10.1089/jop.2015.0080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To evaluate possible changes in pupil size subsequent to panretinal and focal/grid laser photocoagulation. METHODS Sixty-four eyes of 64 participants were included. Thirty-two eyes with planned panretinal photocoagulation formed Group 1, and 32 eyes with planned focal retinal photocoagulation formed Group 2. The participants underwent full ophthalmologic examination at baseline. Automated infrared pupillometry was performed at baseline and month 1. RESULTS The mean pupillary measurements (in millimeters) for Group 1 (in order photopic, mesopic, scotopic) were 3.09 ± 0.69 mm, 3.66 ± 0.85 mm, and 3.87 ± 1.01 mm and changed to 3.34 ± 0.74 mm, 3.82 ± 0.92 mm, and 4.03 ± 1.02 mm. There was a significant increase in pupil size at month 1 (P = 0.001, P = 0.001, P = 0.003). For Group 2, they were 2.65 ± 0.87 mm, 3.08 ± 1.08 mm, and 3.18 ± 1.19 mm and changed to 2.92 ± 0.72 mm, 3.45 ± 0.76 mm, and 3.57 ± 0.88 mm. There was no significant difference in pupil size at month 1 (P = 0.151, P = 0.106, P = 0.095). CONCLUSION We have demonstrated through automated infrared pupillary measurements that panretinal laser photocoagulation may significantly influence pupil size and focal/grid laser photocoagulation may not.
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Affiliation(s)
- Ihsan Yilmaz
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital , Istanbul, Turkey
| | - Miray Faiz
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital , Istanbul, Turkey
| | - Basak Saracoglu
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital , Istanbul, Turkey
| | - Ahmet Taylan Yazici
- Department of Ophthalmology, Beyoglu Eye Training and Research Hospital , Istanbul, Turkey
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18
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Abstract
Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical examination, and laboratory findings to identify structural causes and diagnose treatable disorders. Some patients have a clear diagnosis. In those who do not, the first decision is whether brain imaging is needed. Imaging should be done in post-traumatic coma or when structural brain lesions are probable or possible causes. Patients who do not undergo imaging should be reassessed regularly. If CT is non-diagnostic, a checklist should be used use to indicate whether advanced imaging is needed or evidence is present of a treatable poisoning or infection, seizures including non-convulsive status epilepticus, endocrinopathy, or thiamine deficiency.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Rochester, MN, USA.
| | | | - Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Chen JW, Vakil-Gilani K, Williamson KL, Cecil S. Infrared pupillometry, the Neurological Pupil index and unilateral pupillary dilation after traumatic brain injury: implications for treatment paradigms. SPRINGERPLUS 2014; 3:548. [PMID: 25332854 PMCID: PMC4190183 DOI: 10.1186/2193-1801-3-548] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 09/04/2014] [Indexed: 02/06/2023]
Abstract
Pupillary dysfunction, a concerning finding in the neurologic examination of the patient with an acute traumatic brain injury often dictates the subsequent treatment paradigm. Patients were monitored closely with an infrared pupillometer, with NPi technology, for acute changes in pupillary function. NPi technology applies a scalar value to pupillary function. A retrospective chart review was performed of traumatic brain injury patients with acute unilateral pupillary dilation, admitted to Legacy Emanuel Medical Center’s NeuroTrauma Unit, Portland, OR, and followed as outpatients, between January 2012 and December 2013. Clinical exam findings of pupillary size, NPi scores, and brain Magnetic Resonance Imaging and Computed Tomography images were analyzed. Five traumatic brain injury patients were identified with unilateral pupillary dysfunction with long-term follow-up after the initial injury. Each patient was monitored closely in the trauma bay for neurological deterioration with a pupillometer and the clinical exam. Two patients underwent subsequent intracranial pressure monitoring based on a deteriorating clinical scenario, including consistent abnormal unilateral NPi scores. One patient with consistent abnormal NPi scores and an improved clinical exam did not undergo invasive interventions. Two patients showed early improvement in NPi scores correlating with the normalization of their pupillary reactivity. Anisocoria improved in all patients despite concurrent abnormal NPi scores. Magnetic Resonance Imaging and Computed Tomography imaging studies, with a focus on the third nerve, revealed focal abnormalities consistent with the clinical findings. A unilateral blown pupil and abnormal NPi score in a traumatic brain injury patient are not necessarily indicative of intracranial pressure issues, and must be correlated with the entire clinical scenario, to determine the etiology of the third nerve injury and direct potential therapeutic interventions. Early NPi score normalization suggests pupillary function may improve. We found that NPi scores, as a component of the clinical exam, provide a sensitive, noninvasive and quantitative means of following pupillary function acutely and chronically after a traumatic brain injury.
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Affiliation(s)
- Jefferson William Chen
- Department of Neurological Surgery, Legacy Emanuel Medical Center, 2801 N. Gantenbein Ave, Portland, OR 97227 USA ; Department of Neurological Surgery, University of California Irvine, 200 S. Manchester Ave, Suite 210, Orange, CA 92868 USA
| | - Kiana Vakil-Gilani
- Department of Neurological Surgery, Legacy Emanuel Medical Center, 2801 N. Gantenbein Ave, Portland, OR 97227 USA
| | - Kay Lyn Williamson
- Department of Neurological Surgery, Legacy Emanuel Medical Center, 2801 N. Gantenbein Ave, Portland, OR 97227 USA
| | - Sandy Cecil
- Department of Neurological Surgery, Legacy Emanuel Medical Center, 2801 N. Gantenbein Ave, Portland, OR 97227 USA
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