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Figueroa SA, Olson DM, Kamal A, Aiyagari V. Quantitative Pupillometry: Clinical Applications for the Internist. Am J Med 2024; 137:825-831. [PMID: 38734045 DOI: 10.1016/j.amjmed.2024.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024]
Abstract
From the time of Galen, examination of the pupillary light reflex has been a standard of care across the continuum of health care. The growing body of evidence overwhelmingly supports the use of quantitative pupillometry over subjective examination with flashlight or penlight. At current time, pupillometers have become standard of care in many hospitals across 6 continents. This review paper provides an overview and rationale for pupillometer use and highlights literature supporting pupillometer-derived measures of the pupillary light reflex in both neurological and non-neurological patients across the health care continuum.
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Affiliation(s)
- Stephen A Figueroa
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas; Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas.
| | - DaiWai M Olson
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas; Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas
| | - Abdulkadir Kamal
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas; Department of Nursing, University of Texas Southwestern Medical Center, Dallas
| | - Venkatesh Aiyagari
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas; Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas
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Doyle BR, Aiyagari V, Yokobori S, Kuramatsu JB, Barnes A, Puccio A, Nairon EB, Marshall JL, Olson DM. Anisocoria After Direct Light Stimulus is Associated with Poor Outcomes Following Acute Brain Injury. Neurocrit Care 2024:10.1007/s12028-024-02030-1. [PMID: 38918339 DOI: 10.1007/s12028-024-02030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/31/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Assessing pupil size and reactivity is the standard of care in neurocritically ill patients. Anisocoria observed in critically ill patients often prompts further investigation and treatment. This study explores anisocoria at rest and after light stimulus determined using quantitative pupillometry as a predictor of discharge modified Rankin Scale (mRS) scores. METHODS This analysis includes data from an international registry and includes patients with paired (left and right eye) quantitative pupillometry readings linked to discharge mRS scores. Anisocoria was defined as the absolute difference in pupil size using three common cut points (> 0.5 mm, > 1 mm, and > 2 mm). Nonparametric models were constructed to explore patient outcome using three predictors: the presence of anisocoria at rest (in ambient light); the presence of anisocoria after light stimulus; and persistent anisocoria (present both at rest and after light). The primary outcome was discharge mRS score associated with the presence of anisocoria at rest versus after light stimulus using the three commonly defined cut points. RESULTS This analysis included 152,905 paired observations from 6,654 patients with a mean age of 57.0 (standard deviation 17.9) years, and a median hospital stay of 5 (interquartile range 3-12) days. The mean admission Glasgow Coma Scale score was 12.7 (standard deviation 3.5), and the median discharge mRS score was 2 (interquartile range 0-4). The ranges for absolute differences in pupil diameters were 0-5.76 mm at rest and 0-6.84 mm after light. Using an anisocoria cut point of > 0.5 mm, patients with anisocoria after light had worse median mRS scores (2 [interquartile range 0-4]) than patients with anisocoria at rest (1 [interquartile range 0-3]; P < .0001). Patients with persistent anisocoria had worse median mRS scores (3 [interquartile range 1-4]) than those without persistent anisocoria (1 [interquartile range 0-3]; P < .0001). Similar findings were observed using a cut point for anisocoria of > 1 mm and > 2 mm. CONCLUSIONS Anisocoria after light is a new biomarker that portends worse outcome than anisocoria at rest. After further validation, anisocoria after light should be considered for inclusion as a reported and trended assessment value.
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Affiliation(s)
- Brittany R Doyle
- Department of Nursing, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Venkatesh Aiyagari
- Neurological Surgery and Neurology University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arianna Barnes
- Cardiac Intensive Care Unit, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ava Puccio
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emerson B Nairon
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jade L Marshall
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - DaiWai M Olson
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Bogucki A, John I, Zinkiewicz Ł, Jachura M, Jaworski D, Suwała K, Chrost H, Wlodarski M, Kałużny J, Campbell D, Bakken P, Pandya S, Chrapkiewicz R, Manohar SG. Machine learning approach for ambient-light-corrected parameters and the Pupil Reactivity (PuRe) score in smartphone-based pupillometry. Front Neurol 2024; 15:1363190. [PMID: 38654735 PMCID: PMC11037402 DOI: 10.3389/fneur.2024.1363190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/18/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction The pupillary light reflex (PLR) is the constriction of the pupil in response to light. The PLR in response to a pulse of light follows a complex waveform that can be characterized by several parameters. It is a sensitive marker of acute neurological deterioration, but is also sensitive to the background illumination in the environment in which it is measured. To detect a pathological change in the PLR, it is therefore necessary to separate the contributions of neuro-ophthalmic factors from ambient illumination. Illumination varies over several orders of magnitude and is difficult to control due to diurnal, seasonal, and location variations. Methods and results We assessed the sensitivity of seven PLR parameters to differences in ambient light, using a smartphone-based pupillometer (AI Pupillometer, Solvemed Inc.). Nine subjects underwent 345 measurements in ambient conditions ranging from complete darkness (<5 lx) to bright lighting (≲10,000 lx). Lighting most strongly affected the initial pupil size, constriction amplitude, and velocity. Nonlinear models were fitted to find the correction function that maximally stabilized PLR parameters across different ambient light levels. Next, we demonstrated that the lighting-corrected parameters still discriminated reactive from unreactive pupils. Ten patients underwent PLR testing in an ophthalmology outpatient clinic setting following the administration of tropicamide eye drops, which rendered the pupils unreactive. The parameters corrected for lighting were combined as predictors in a machine learning model to produce a scalar value, the Pupil Reactivity (PuRe) score, which quantifies Pupil Reactivity on a scale 0-5 (0, non-reactive pupil; 0-3, abnormal/"sluggish" response; 3-5, normal/brisk response). The score discriminated unreactive pupils with 100% accuracy and was stable under changes in ambient illumination across four orders of magnitude. Discussion This is the first time that a correction method has been proposed to effectively mitigate the confounding influence of ambient light on PLR measurements, which could improve the reliability of pupillometric parameters both in pre-hospital and inpatient care settings. In particular, the PuRe score offers a robust measure of Pupil Reactivity directly applicable to clinical practice. Importantly, the formulae behind the score are openly available for the benefit of the clinical research community.
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Affiliation(s)
| | - Ivo John
- Solvemed Inc., Lewes, DE, United States
| | | | | | - Damian Jaworski
- Oftalmika Eye Hospital, Bydgoszcz, Poland
- Division of Ophthalmology and Optometry, Department of Ophthalmology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Karolina Suwała
- Oftalmika Eye Hospital, Bydgoszcz, Poland
- Department of Sensory Organ Studies, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | | | - Jakub Kałużny
- Oftalmika Eye Hospital, Bydgoszcz, Poland
- Department of Sensory Organ Studies, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Doug Campbell
- Space Medicine Group, International Institute for Astronautical Sciences, Boulder, CO, United States
| | - Paul Bakken
- Space Medicine Group, International Institute for Astronautical Sciences, Boulder, CO, United States
| | - Shawna Pandya
- Space Medicine Group, International Institute for Astronautical Sciences, Boulder, CO, United States
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Ali AMS, Gul W, Sen J, Hewitt SJ, Olubajo F, McMahon C. Evaluating the utility of quantitative pupillometry in a neuro-critical care setting for the monitoring of intracranial pressure: A prospective cohort study. Clin Neurol Neurosurg 2024; 239:108215. [PMID: 38447480 DOI: 10.1016/j.clineuro.2024.108215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Assessment of the pupillary light reflex (PLR) is key in intensive care monitoring of neurosurgical patients, particularly for monitoring intracranial pressure (ICP). Quantitative pupillometry using a handheld pupillometer is a reliable method for PLR assessment. However, many variables are derived from such devices. We therefore aimed to assess the performance of these variables at monitoring ICP. METHODS Sedated patients admitted to neurocritical care in a tertiary neurosurgical centre with invasive ICP monitoring were included. Hourly measurement of ICP, subjective pupillometry (SP) using a pen torch device, and quantitative pupillometry (QP) using a handheld pupillometer were performed. RESULTS 561 paired ICP, SP and QP pupillary observations from nine patients were obtained (1122 total pupillary observations). SP and QP had a moderate concordance for pupillary size (κ=0.62). SP performed poorly at detecting pupillary size changes (sensitivity=24%). In 40 (3.6%) observations, SP failed to detect a pupillary response whereas QP did. Moderate correlations with ICP were detected for maximum constriction velocity (MCV), dilation velocity (DV), and percentage change in pupillary diameter (%C). Discriminatory ability at an ICP threshold of >22 mmHg was moderate for MCV (AUC=0.631), DV (AUC=0.616), %C (AUC=0.602), and pupillary maximum size (AUC=0.625). CONCLUSION QP is superior to SP at monitoring pupillary reactivity and changes to pupillary size. Although effect sizes were moderate to weak across assessed variables, our data indicates MCV and %C as the most sensitive variables for monitoring ICP. Further study is required to validate these findings and to establish normal range cut-offs for clinical use.
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Affiliation(s)
- Ahmad M S Ali
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.
| | - Wisha Gul
- St Helens and Knowsley NHS Foundation Trust, Prescot, UK
| | - Jon Sen
- School of Medicine, Keele University, Newcastle-under-Lyme, UK
| | - Sarah-Jane Hewitt
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Farouk Olubajo
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Catherine McMahon
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Vrettou CS, Fragkou PC, Mallios I, Barba C, Giannopoulos C, Gavrielatou E, Dimopoulou I. The Role of Automated Infrared Pupillometry in Traumatic Brain Injury: A Narrative Review. J Clin Med 2024; 13:614. [PMID: 38276120 PMCID: PMC10817296 DOI: 10.3390/jcm13020614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/15/2024] [Accepted: 01/20/2024] [Indexed: 01/27/2024] Open
Abstract
Pupillometry, an integral component of neurological examination, serves to evaluate both pupil size and reactivity. The conventional manual assessment exhibits inherent limitations, thereby necessitating the development of portable automated infrared pupillometers (PAIPs). Leveraging infrared technology, these devices provide an objective assessment, proving valuable in the context of brain injury for the detection of neuro-worsening and the facilitation of patient monitoring. In cases of mild brain trauma particularly, traditional methods face constraints. Conversely, in severe brain trauma scenarios, PAIPs contribute to neuro-prognostication and non-invasive neuromonitoring. Parameters derived from PAIPs exhibit correlations with changes in intracranial pressure. It is important to acknowledge, however, that PAIPs cannot replace invasive intracranial pressure monitoring while their widespread adoption awaits robust support from clinical studies. Ongoing research endeavors delve into the role of PAIPs in managing critical neuro-worsening in brain trauma patients, underscoring the non-invasive monitoring advantages while emphasizing the imperative for further clinical validation. Future advancements in this domain encompass sophisticated pupillary assessment tools and the integration of smartphone applications, emblematic of a continually evolving landscape.
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Affiliation(s)
- Charikleia S. Vrettou
- First Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Medical School, National and Kapodistrian University of Athens, 10676 Athens, Greece (I.D.)
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Saju C, Barnes A, Kuramatsu JB, Marshall JL, Obinata H, Puccio AM, Yokobori S, Olson DM. Describing Anisocoria in Neurocritically Ill Patients. Am J Crit Care 2023; 32:402-409. [PMID: 37907374 DOI: 10.4037/ajcc2023558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
BACKGROUND Anisocoria (unequal pupil size) has been defined using cut points ranging from greater than 0.3 mm to greater than 2.0 mm for absolute difference in pupil size. This study explored different pupil diameter cut points for assessing anisocoria as measured by quantitative pupillometry before and after light stimulus. METHODS An exploratory descriptive study of international registry data was performed. The first observations in patients with paired left and right quantitative pupillometry measurements were included. Measurements of pupil size before and after stimulus with a fixed light source were used to calculate anisocoria. RESULTS The sample included 5769 patients (mean [SD] age, 57.5 [17.6] years; female sex, 2558 patients [51.5%]; White race, 3669 patients [75.5%]). Anisocoria defined as pupil size difference of greater than 0.5 mm was present in 1624 patients (28.2%) before light stimulus; 645 of these patients (39.7%) also had anisocoria after light stimulus (P < .001). Anisocoria defined as pupil size difference of greater than 2.0 mm was present in 79 patients (1.4%) before light stimulus; 42 of these patients (53.2%) also had anisocoria after light stimulus (P < .001). DISCUSSION The finding of anisocoria significantly differed before and after light stimulus and according to the cut point used. At most cut points, fewer than half of the patients who had anisocoria before light stimulus also had anisocoria after light stimulus. CONCLUSION The profound difference in the number of patients adjudicated as having anisocoria using different cut points reinforces the need to develop a universal definition for anisocoria.
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Affiliation(s)
- Ciji Saju
- Ciji Saju is an assistant nurse manager, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Arianna Barnes
- Arianna Barnes is a clinical nurse specialist at Barnes-Jewish Hospital, St Louis, Missouri
| | - Joji B Kuramatsu
- Joji B. Kuramatsu is a professor at University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jade L Marshall
- Jade L. Marshall is a clinical research associate, University of Texas Southwestern Medical Center
| | - Hirofumi Obinata
- Hirofumi Obinata is a research associate at Nippon Medical School, Tokyo, Japan
| | - Ava M Puccio
- Ava M. Puccio is an associate professor at University of Pittsburgh, Pennsylvania
| | | | - DaiWai M Olson
- DaiWai M. Olson is a professor at University of Texas Southwestern Medical Center
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Jiang J, Sari H, Goldman R, Huff E, Hanna A, Samraj R, Gourabathini H, Bhalala U. Neurological Pupillary Index (NPi) Measurement Using Pupillometry and Outcomes in Critically Ill Children. Cureus 2023; 15:e46480. [PMID: 37927706 PMCID: PMC10624239 DOI: 10.7759/cureus.46480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Aim/objective Neurological Pupil Index (NPi), measured by automated pupillometry (AP), allows the objective assessment of pupillary light reflex (PLR). NPi ranges from 0 (non-reactive) to 5 (normal). In this study, we aimed to compare neurologic and functional outcomes in children admitted for neurologic injury with normal (≥3) versus abnormal (<3) NPi measured during their pediatric intensive care unit (PICU) stay. Materials and methods We conducted a retrospective chart review of children between one month and 18 years admitted to our PICU with a diagnosis of neurologic injury between January 2019 and June 2022. We collected demographic, clinical, pupillometer, and outcome data, including mortality, Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and Functional Status Score (FSS) at admission, at discharge, and at the three to six-month follow-up. We defined abnormal pupil response as any NPi <3 at any point during the PICU stay. Using the student's t-test and chi-square test, we compared the short-term and long-term outcomes of children with abnormal NPi (<3) versus those with normal NPi (≥3). Results There were 49 children who met the inclusion criteria and who had pupillometry data available for analysis. The mean (SD) Glasgow Coma Scale (GCS) in the study cohort was 5.6 (4.3), and 61% had low (<3) NPi during ICU stay. Mortality was significantly higher among patients with an abnormal NPi as compared to those with normal NPi. Children with abnormal NPi exhibited significant worsening of neurologic and functional status (ΔPCPC, ΔPOPC, and ΔFSS) from admission to discharge (mean (SD): 3.55(1.5), 3.45(1.43), 16.75(7.85), p<0.001) as compared to those with normal NPi (mean (SD): 1.45(0.93), 1.73(0.90), 3.55(2.07), p>0.05). The significant difference in neurologic and functional status persisted at the three to six-month follow-up between the two groups - children with abnormal NPi (mean (SD): 2.0(1.41), 2.08(1.38), 6.92(6.83), p<0.01) and children with normal NPi (mean (SD): 0.82(1.01), 0.94(1.03), 1.53(1.70), p>0.05). Conclusion In our retrospective cohort study, children admitted to the PICU for a neuro injury and with abnormal NPi (< 3) have higher mortality, and worse short-term and long-term neurologic and functional outcomes as compared to those with normal NPi (≥ 3) measured during the PICU course. AP provides an objective assessment of PLR and has potential applications for neuro-prognostication. More research needs to be done to elucidate the prognostic value of NPi in pediatrics.
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Affiliation(s)
- Jessie Jiang
- Medicine, Texas A&M College of Medicine, Round Rock, USA
| | - Halil Sari
- Statistics, Texas A&M College of Medicine, Round Rock, USA
| | - Rachelle Goldman
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | - Erionne Huff
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | - Ashley Hanna
- Pediatric Neurosurgery, Driscoll Children's Hospital, Corpus Christi, USA
| | - Ravi Samraj
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | | | - Utpal Bhalala
- Pediatrics, Texas A&M College of Medicine, College Station, USA
- Anesthesiology and Critical Care, Driscoll Children's Hospital, Corpus Christi, USA
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Kirk C, Childs C. Combat Sports as a Model for Measuring the Effects of Repeated Head Impacts on Autonomic Brain Function: A Brief Report of Pilot Data. Vision (Basel) 2023; 7:vision7020039. [PMID: 37218957 DOI: 10.3390/vision7020039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/12/2023] [Accepted: 04/29/2023] [Indexed: 05/24/2023] Open
Abstract
Automated pupil light reflex (PLR) is a valid indicator of dysfunctional autonomic brain function following traumatic brain injury. PLR's use in identifying disturbed autonomic brain function following repeated head impacts without outwardly visible symptoms has not yet been examined. As a combat sport featuring repeated 'sub-concussive' head impacts, mixed martial arts (MMA) sparring may provide a model to understand such changes. The aim of this pilot study was to explore which, if any, PLR variables are affected by MMA sparring. A cohort of n = 7 MMA athletes (age = 24 ± 3 years; mass = 76.5 ± 9 kg; stature = 176.4 ± 8.5 cm) took part in their regular sparring sessions (eight rounds × 3 min: 1 min recovery). PLR of both eyes was measured immediately pre- and post-sparring using a Neuroptic NPi-200. Bayesian paired samples t-tests (BF10 ≥ 3) revealed decreased maximum pupil size (BF10 = 3), decreased minimum pupil size (BF10 = 4) and reduced PLR latency (BF10 = 3) post-sparring. Anisocoria was present prior to sparring and increased post-sparring, with both eyes having different minimum and maximum pupil sizes (BF10 = 3-4) and constriction velocities post-sparring (BF10 = 3). These pilot data suggest repeated head impacts may cause disturbances to autonomic brain function in the absence of outwardly visible symptoms. These results provide direction for cohort-controlled studies to formally investigate the potential changes observed.
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Affiliation(s)
- Christopher Kirk
- Health Research Institute, Sheffield Hallam University, Sheffield S10 2NA, UK
| | - Charmaine Childs
- Health Research Institute, Sheffield Hallam University, Sheffield S10 2NA, UK
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Pupillary light reflex measured with quantitative pupillometry has low sensitivity and high specificity for predicting neuroworsening after traumatic brain injury. J Am Assoc Nurse Pract 2023; 35:130-134. [PMID: 36763466 DOI: 10.1097/jxx.0000000000000822] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Triage and neurological assessment of the 1.7 million traumatic brain injuries occurring annually is often done by nurse practitioners and physician assistants in the emergency department. Subjective assessments, such as the neurological examination that includes evaluation of the pupillary light reflex (PLR), can contain bias. Quantitative pupillometry (QP) standardizes and objectifies the PLR examination. Additional data are needed to determine whether QP can predict neurological changes in a traumatic brain injury (TBI) patient. PURPOSE This study examines the effectiveness of QP in predicting neurological decline within 24 hours of admission following acute TBI. METHODOLOGY This prospective, observational, clinical trial used pragmatic sampling to assess PLR in TBI patients using QP within 24 hours of ED admission. Chi-square analysis was used to determine change in patient status, through Glasgow Coma Scale (GCS), at baseline and within 24 hours of admission, to the QP. RESULTS There were 95 participants included in the analysis; of whom 35 experienced neuroworsening, defined by change in GCS of >2 within the first 24 hours of admission. There was a significant association between an abnormal Neurological Pupil index (NPi), defined as NPi of <3, and neuroworsening (p < .0001). The sensitivity (51.43%) and specificity (91.67%) of abnormal NPi in predicting neuroworsening were varied. CONCLUSION There is a strong association between abnormal NPi and neuroworsening in the sample of TBI patients with high specificity and moderate sensitivity. IMPLICATIONS NPi may be an early indicator of neurological changes within 24 hours of ED admission in patients with TBI.
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Privitera CM, Neerukonda SV, Aiyagari V, Yokobori S, Puccio AM, Schneider NJ, Stutzman SE, Olson DM, Hill M, DeWitt J, Atem F, Barnes A, Xie D, Kuramatsu J, Koehn J, Swab S. A differential of the left eye and right eye neurological pupil index is associated with discharge modified Rankin scores in neurologically injured patients. BMC Neurol 2022; 22:273. [PMID: 35869429 PMCID: PMC9306158 DOI: 10.1186/s12883-022-02801-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Automated infrared pupillometry (AIP) and the Neurological Pupil index (NPi) provide an objective means of assessing and trending the pupillary light reflex (PLR) across a broad spectrum of neurological diseases. NPi quantifies the PLR and ranges from 0 to 5; in healthy individuals, the NPi of both eyes is expected to be ≥ 3.0 and symmetric. AIP values demonstrate emerging value as a prognostic tool with predictive properties that could allow practitioners to anticipate neurological deterioration and recovery. The presence of an NPi differential (a difference ≥ 0.7 between the left and right eye) is a potential sign of neurological abnormality.
Methods
We explored NPi differential by considering the modified Rankin Score at discharge (DC mRS) among patients admitted to neuroscience intensive care units (NSICU) of 4 U.S. and 1 Japanese hospitals and for two cohorts of brain injuries: stroke (including subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, and aneurysm, 1,200 total patients) and 185 traumatic brain injury (TBI) patients for a total of more than 54,000 pupillary measurements.
Results
Stroke patients with at least 1 occurrence of an NPi differential during their NSICU stay have higher DC mRS scores (3.9) compared to those without an NPi differential (2.7; P < .001). Patients with TBI and at least 1 occurrence of an NPi differential during their NSICU stay have higher discharge modified Rankin Scale scores (4.1) compared to those without an NPi differential (2.9; P < .001). When patients experience both abnormalities, abnormal (NPi < 3.0) and an NPi differential, the latter has an anticipatory relationship with respect to the former (P < .001 for z-score skewness analysis). Finally, our analysis confirmed ≥ 0.7 as the optimal cutoff value for the NPi differential (AUC = 0.71, P < .001).
Conclusion
The NPi differential is an important factor that clinicians should consider when managing critically ill neurological injured patients admitted to the neurocritical care units.
Trial registration
NCT02804438, Date of Registration: June 17, 2016.
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Romano A, Guglielmino V, Di Paolantonio A, Bisogni G, Sabatelli M, Della Marca G, Minnella AM, Maceroni M, Bellavia S, Scala I, Sabatelli E, Rollo E, Luigetti M. Pupillometric findings in ATTRv patients and carriers: results from a single-centre experience. Amyloid 2022; 29:270-275. [PMID: 36066019 DOI: 10.1080/13506129.2022.2117601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Hereditary transthyretin amyloidosis (ATTRv) is a treatable multisystemic disease with great phenotypic heterogeneity. Among extra-neurological features, pupillary abnormalities have been reported, either related to amyloid deposition in the eye or to a progressive autonomic neuropathy. OBJECTIVE To evaluate the role of automated pupillometry, a non-invasive and rapid test able to provide objective and reproducible data on pupil size and reactivity, as a marker of disease severity in late-onset ATTRv patients. PATIENTS AND METHODS We performed automated pupillometry on a cohort of ATTRv patients and pre-symptomatic TTR mutation carriers and compared results to healthy controls. An exhaustive clinical and instrumental evaluation was performed on all enrolled subjects. RESULTS A statistically significant difference in most pupillometry parameters was found in ATTRv patients as compared to both carriers and healthy controls. Moreover, in ATTRv patients, we found a significant correlation between many pupillometry findings and disease duration, as well as widely accepted clinical scales and investigations (NIS, Sudoscan from feet, and Norfolk QoL-DN questionnaire). CONCLUSIONS We suggest pupillometry may play a role as a reliable and non-invasive biomarker to evaluate ATTRv disease severity and monitor its progression.
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Affiliation(s)
- Angela Romano
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valeria Guglielmino
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Giulia Bisogni
- Centro Clinico NeMO Adulti, Fondazione Serena Onlus-Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mario Sabatelli
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy.,Centro Clinico NeMO Adulti, Fondazione Serena Onlus-Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giacomo Della Marca
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angelo Maria Minnella
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Oftalmologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Martina Maceroni
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC Oftalmologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Simone Bellavia
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Irene Scala
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eleonora Sabatelli
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eleonora Rollo
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Luigetti
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
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12
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Reflections on Patient Care Technicians Obtaining Pupillometer Readings in a Neuroscience Intensive Care Unit. J Neurosci Nurs 2022; 54:245-246. [PMID: 36255197 DOI: 10.1097/jnn.0000000000000676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Jolkovsky EL, Fernandez‐Penny FE, Alexis M, Benson LN, Wang BH, Abella BS. Impact of acute intoxication on quantitative pupillometry assessment in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12825. [PMID: 36311337 PMCID: PMC9601771 DOI: 10.1002/emp2.12825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/24/2022] [Accepted: 09/02/2022] [Indexed: 11/11/2022] Open
Abstract
Study Hypothesis/Objective This prospective cohort study aimed to assess whether and to what extent different quantitative pupillometry (QP) metrics are associated with different intoxicant drug classes as well as investigate the potential benefit of QP as a tool in the rapid assessment of clinically intoxicated patients in the emergency department (ED). Methods Between February 25, 2019 and April 24, 2021, 325 patients were enrolled in the EDs of the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC). Patients deemed clinically intoxicated or in withdrawal by an attending emergency physician were considered for eligibility. Patients <18 years old, with a chief complaint indicative of head trauma or stroke or without a urine drug screen (UDS) positive for drugs of abuse were excluded. QP data were also collected from a cohort of 82 healthy control subjects. Results Neurological Pupil index (NPi) values did not vary significantly between control and study groups nor between study group patients with a UDS positive for opioids. With exception of latency of constriction, all other QP metrics for the study group were depressed relative to controls (P < 0.005). Conclusions This work demonstrated the feasibility of QP measurement in the ED, finding that NPi remains unaffected by clinical intoxication and therefore can potentially be used for ED patient evaluation without risk of confounding by key intoxicants of abuse. Future work will evaluate the value of QP as a means of rapid and reproducible neurological assessment to identify various pathologies.
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Affiliation(s)
- Eliana L. Jolkovsky
- David Geffen School of MedicineUniversity of CaliforniaLos AngelesLos AngelesCaliforniaUSA
| | - Felix E. Fernandez‐Penny
- Department of Emergency MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Penn Acute Research CollaborationUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Maya Alexis
- Department of Emergency MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Lauren N. Benson
- Department of Emergency MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Bo Hwan Wang
- Department of Emergency MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Benjamin S. Abella
- Department of Emergency MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Penn Acute Research CollaborationUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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14
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Lussier BL, Erapuram M, White JA, Stutzman SE, Olson DM. Predictive value of quantitative pupillometry in patients with normal pressure hydrocephalus undergoing temporary CSF diversion. Neurol Sci 2022; 43:5377-5382. [DOI: 10.1007/s10072-022-06230-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/17/2022] [Indexed: 10/17/2022]
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15
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Harmonization of Physiological Data in Neurocritical Care: Challenges and a Path Forward. Neurocrit Care 2022; 37:202-205. [PMID: 35641807 DOI: 10.1007/s12028-022-01524-0] [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: 12/20/2021] [Accepted: 04/20/2022] [Indexed: 10/18/2022]
Abstract
Continuous multimodal monitoring in neurocritical care provides valuable insights into the dynamics of the injured brain. Unfortunately, the "readiness" of this data for robust artificial intelligence (AI) and machine learning (ML) applications is low and presents a significant barrier for advancement. Harmonization standards and tools to implement those standards are key to overcoming existing barriers. Consensus in our professional community is essential for success.
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16
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Kamal A, Ahmed KM, Venkatachalam AM, Osman M, Aoun SG, Aiyagari V, Schneider N, Hasan-Washington H, Stutzman SE, Olson DM. Pilot Study of Neurologic Pupil Index as A Predictor of External Ventricular Drain Clamp Trial Failure After Subarachnoid Hemorrhage. World Neurosurg 2022; 164:2-7. [PMID: 35525437 DOI: 10.1016/j.wneu.2022.04.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND External ventricular drains (EVDs) provide a temporary egress for cerebrospinal fluid (CSF) in patients with symptomatic hydrocephalus following aneurysmal subarachnoid hemorrhage. Before EVD removal, a wean trial, which involves clamping the EVD, is typically attempted to ensure that CSF self-regulation is achieved. Automated infrared pupillometry (AIP) has been shown to detect early neurologic decline. We sought to explore the use of AIP to detect early EVD clamping trial failure. METHODS This prospective observational pilot study enrolled aneurysmal subarachnoid hemorrhage patients before an EVD clamp trial. On initiating the clamp trial, nurses included hourly AIP assessment in documentation. Clamp trial outcome was based on neurologic examination and neuroimaging. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) models were constructed to explore computed tomography (CT) versus AIP as predictors of clamp trial outcome. RESULTS Among the 30 subjects enrolled, there were 38 clamping trials and 22 successful EVD removals. CT scan as a predictor of clamp trial was found to have a sensitivity of 68.8% and specificity of 89.5% (PPV = 84.6%, NPV = 77.3%). AIP assessment as a predictor of wean trial outcome was found to have a sensitivity of 58.3% and specificity of 100% (PPV = 100%, NPV = 63.2%). CONCLUSIONS The pilot study data support that Neurological Pupil index <3 is a potential indicator of early clamp trial failure, but a CT scan has a higher sensitivity and NPV for predicting successful EVD removal. This finding suggests the benefits of including AIP assessments during clamping trials.
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Affiliation(s)
- Abdulkadir Kamal
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Khalid M Ahmed
- University of Texas Houston McGovern Medical School, Department of Pulmonary and Critical Care Medicine, Houston, Texas, USA
| | - Aardhra M Venkatachalam
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA; Ross University School of Medicine, Miramar, Florida, USA
| | - Mohamed Osman
- Texas Health Harris Methodist, Fort Worth, Texas, USA
| | - Salah G Aoun
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Venkatesh Aiyagari
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Nathan Schneider
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Heather Hasan-Washington
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - Sonja E Stutzman
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA
| | - DaiWai M Olson
- The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA.
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17
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Inter-device reliability of the NPi-200 and NPi-300 pupillometers. J Clin Neurosci 2022; 100:180-183. [PMID: 35487025 DOI: 10.1016/j.jocn.2022.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/22/2022] [Accepted: 04/20/2022] [Indexed: 11/22/2022]
Abstract
The pupillary evaluation is an essential part of the neurological examination. Research suggests that the traditional examination of the pupil with a handheld flashlight has limited interrater reliability. Automated pupillometers were developed to provide an objective scoring of various pupillary parameters. The NPi-200 pupillometer is used for quantitative pupillary examinations, the NPi-300 was launched in July 2021 with enhanced features. The purpose of this study is to compare results from the NPi-200 to the NPi-300 to ensure that data are translatable across both platforms. This study examines the inter-device reliability of the NPi-200 compared to the NPi-300 in two cohorts: 20 patients at risk for cerebral edema and 50 healthy controls. Paired assessments of the devices were made from all participants. Each assessment included bilateral PLR readings within a 5-minute interval. Data showed high agreement between the two devices for the Neurological Pupil Index (NPi) reading (k = 0.94; CI: 0.91-0.99) and for pupil diameter assessment (k = 0.91; CI: 0.87-0.96). There is a very high level of agreement between the NPi-200 and NPi-300 among healthy controls and critically ill patients. Clinicians and researchers can interpret the results from either device equally.
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18
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Giamarino K, Blessing R, Boelter C, Thompson JA, Reynolds SS. Exploring the Relationship Between Objective Pupillometry Metrics and Midline Shift. J Neurosci Nurs 2021; 53:233-237. [PMID: 34593723 DOI: 10.1097/jnn.0000000000000614] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT BACKGROUND: Pupillary examinations provide early subtle signs of worsening intracranial pathology. Objective pupillomtery assessment, although not yet the standard of care, is considered best practice. However, inconsistent findings from objective pupillometry studies have caused a lack of consensus among clinicians; as such, no clinical guidelines are available to guide clinical use of objective pupillometer devices. To add to the body of evidence, the purpose of this project was to explore the relationship between objective pupillometry metrics and midline shift (MLS). METHODS: A retrospective chart review of pupillometer data was conducted. Midline shift was correlated with objective pupillometry metrics including Neurological Pupil Index (NPi), pupil size, and anisocoria. Midline shift was measured for the patient's initial neuroimaging and with any defined neurological change. Spearman ρ was used for statistical analysis of correlations between pupillometer metrics and MLS measured at both the septum pellucidum and pineal gland. RESULTS: A total of 41 patients were included in the analysis; most were White (58.5%) and male (58.5%), with a mean (SD) age of 58.49 (16.92) years. Spearman ρ revealed statistically significant positive correlations between right pupil NPi and anisocoria with MLS, and significant negative correlations between left pupil NPi and pupil size with MLS. CONCLUSIONS: Results from this project are consistent with previous studies. Objective pupillometry continues to be a valuable component of a comprehensive neurological examination, because it has the ability to discern early and subtle changes in a patient's neurological status, leading to lifesaving interventions.
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19
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Nyancho D, Atem FD, Venkatachalam AM, Barnes A, Hill M, Traylor JI, Stutzman SE, Bedros N, Aiyagari V, Aoun SG. Anisocoria Correlates With Injury Severity and Outcomes After Blunt Traumatic Brain Injury. J Neurosci Nurs 2021; 53:251-255. [PMID: 34620803 DOI: 10.1097/jnn.0000000000000613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: Automated infrared pupillometry (AIP) has been shown to be helpful in the setting of aneurysmal subarachnoid hemorrhage and stroke as an indicator of imminent irreversible brain injury. We postulated that the early detection of pupillary dysfunction after light stimulation using AIP may be useful in patients with traumatic brain injury (TBI). METHODS: We performed a retrospective review of the Establishing Normative Data for Pupillometer Assessment in Neuroscience Intensive Care database, a prospectively populated multicenter registry of patients who had AIP measurements taken during their intensive care unit admission. The primary eligibility criterion was a diagnosis of blunt TBI. Ordinal logistic modeling was used to explore the association between anisocoria and daily Glasgow Coma Scale scores and discharge modified Rankin Scale scores from the intensive care unit and from the hospital. RESULTS: Among 118 subjects in the who met inclusion, there were 6187 pupillometer readings. Of these, anisocoria in ambient light was present in 12.8%, and that after light stimulation was present in 9.8%. Anisocoria after light stimulation was associated with worse injury severity (odds ratio [OR], 0.26 [95% confidence interval (CI), 0.14-0.46]), lower discharge Glasgow Coma Scale scores (OR, 0.28 [95% CI, 0.17-0.45]), and lower discharge modified Rankin Scale scores (OR, 0.28 [95% CI, 0.17-0.47]). Anisocoria in ambient light showed a similar but weaker association. CONCLUSION: Anisocoria correlates with injury severity and with patient outcomes after blunt TBI. Anisocoria after light stimulation seems to be a stronger predictor than does anisocoria in ambient light. These findings represent continued efforts to understand pupillary changes in the setting of TBI.
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20
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Detection of opioid effect with pupillometry. Auton Neurosci 2021; 235:102869. [PMID: 34474355 DOI: 10.1016/j.autneu.2021.102869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/16/2021] [Accepted: 08/12/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Opioids produce pupillary constriction but their impact on pupillary unrest and the dynamic parameters of the pupillary light reflex have not been characterized. Given the increasing use of portable pupillometers for care of critically ill patients, it is important to distinguish between opioid effects on the pupil versus those that have been reported to arise from traumatic and ischemic brain insults. We undertook this study to determine which pupillary responses are most profoundly and consistently affected by a progressive infusion of remifentanil. METHODS We studied the effect of remifentanil on the pupil using two portable infrared pupillometers in 18 volunteers. One pupillometer measured pupillary unrest in ambient light (PUAL) and the other pupillometer measured neurological pupillary index (NPi), constriction velocity (CV), pupil diameter (PD), latency, and % reflex (% reflex) following a transient light flash. Remifentanil was administered at predetermined weight-adjusted rates to raise opioid effect site concentration up to a range known to produce respiratory depression and oxyhemoglobin desaturation, based on a previously published pharmacokinetic model. RESULTS PUAL was ablated by remifentanil, declining 94 ± 6% from baseline at the time of maximum drug effect. Other pupillary measurements decreased 50-65% from baseline. NPi was unchanged. At the time of oxyhemoglobin desaturation, deviations in PD, CV, and % reflex were widely scattered, whereas PUAL consistently approached zero. CONCLUSION PUAL is a highly specific indicator of central opioid effect. As a non-invasive measure, it may provide useful data to clinicians who prescribe opioids.
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21
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Traylor JI, El Ahmadieh TY, Bedros NM, Al Adli N, Stutzman SE, Venkatachalam AM, Pernik MN, Collum CM, Douglas PM, Aiyagari V, Bagley CA, Olson DM, Aoun SG. Quantitative pupillometry in patients with traumatic brain injury and loss of consciousness: A prospective pilot study. J Clin Neurosci 2021; 91:88-92. [PMID: 34373065 DOI: 10.1016/j.jocn.2021.06.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/23/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Loss of consciousness (LOC) is a hallmark feature in Traumatic Brain Injury (TBI), and a strong predictor of outcomes after TBI. The aim of this study was to describe associations between quantitative infrared pupillometry values and LOC, intracranial hypertension, and functional outcomes in patients with TBI. METHODS We conducted a prospective study of patients evaluated at a Level 1 trauma center between November 2019 and February 2020. Pupillometry values including the Neurological Pupil Index (NPi), constriction velocity (CV), and dilation velocity (DV) were obtained. RESULTS Thirty-six consecutive TBI patients were enrolled. The median (range) age was 48 (range 21-86) years. The mean Glasgow Coma Scale score on arrival was 11.8 (SD = 4.0). DV trichotomized as low (<0.5 mm/s), moderate (0.5-1.0 mm/s), or high (>1.0 mm/s) was significantly associated with LOC (P = .02), and the need for emergent intervention (P < .01). No significant association was observed between LOC and NPi (P = .16); nor between LOC and CV (P = .07). CONCLUSIONS Our data suggests that DV, as a discrete variable, is associated with LOC in TBI. Further investigation of the relationship between discrete pupillometric variables and NPi may be valuable to understand the clinical significance of the pupillary light reflex findings in acute TBI.
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Affiliation(s)
- Jeffrey I Traylor
- UT Southwestern Medical Center, Department of Neurological Surgery, USA
| | | | - Nicole M Bedros
- Baylor University Medical Center, Division of Trauma, Department of Surgery, USA
| | - Nadeem Al Adli
- UT Southwestern Medical Center, Department of Neurological Surgery, USA
| | | | | | - Mark N Pernik
- UT Southwestern Medical Center, Department of Neurological Surgery, USA
| | - C Munro Collum
- UT Southwestern Medical Center, O'Donnell Brain Institute, USA
| | - Peter M Douglas
- Department of Molecular Biology, USA; Hamon Center for Regenerative Science and Medicine, USA
| | - Venkatesh Aiyagari
- UT Southwestern Medical Center, Department of Neurology, USA; UT Southwestern Medical Center, Department of Neuro-Critical Care, USA
| | - Carlos A Bagley
- UT Southwestern Medical Center, Department of Neurological Surgery, USA
| | - DaiWai M Olson
- UT Southwestern Medical Center, Department of Neurology, USA; UT Southwestern Medical Center, Department of Neuro-Critical Care, USA
| | - Salah G Aoun
- UT Southwestern Medical Center, Department of Neurological Surgery, USA.
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22
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Singh P, Stutzman SE, Venkatachalam A, Olson DM, Barnes A, Atem FD. Identification of abnormal pupil dilation velocity as a biomarker of cerebral injury in neurocritically ill patients. Rev Bras Ter Intensiva 2021; 33:412-421. [PMID: 35107552 PMCID: PMC8555398 DOI: 10.5935/0103-507x.20210065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/02/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To calculate mean dilation velocities for Glasgow coma scale-derived injury severity classifications stratified by multiple confounding variables. METHODS In this study, we examined 68,813 pupil readings from 3,595 patients to determine normal dilation velocity with brain injury categorized based upon a Glasgow coma scale as mild (13 - 15), moderate (9 - 12), or severe (3 - 8). The variables age, sex, race, pupil size, intensive care unit length of stay, intracranial pressure, use of narcotics, Glasgow coma scale, and diagnosis were considered as confounding and controlled for in statistical analysis. Machine learning classification algorithm-based logistic regression was employed to identify dilation velocity cutoffs for Glasgow coma scale categories. RESULTS The odds ratios and confidence intervals of these factors were shown to be statistically significant in their influence on dilation velocity. Classification based on the area under the curve showed that for the mild Glasgow coma scale, the dilation velocity threshold value was 1.2mm/s, with false probability rates of 0.1602 and 0.1902 and areas under the curve of 0.8380 and 0.8080 in the left and right eyes, respectively. For the moderate Glasgow coma scale, the dilation velocity was 1.1mm/s, with false probability rates of 0.1880 and 0.1940 and areas under the curve of 0.8120 and 0.8060 in the left and right eyes, respectively. Furthermore, for the severe Glasgow coma scale, the dilation velocity was 0.9mm/s, with false probability rates of 0.1980 and 0.2060 and areas under the curve of 0.8020 and 0.7940 in the left and right eyes, respectively. These values were different from the previous method of subjective description and from previously estimated normal dilation velocities. CONCLUSION Slower dilation velocities were observed in patients with lower Glasgow coma scores, indicating that decreasing velocities may indicate a higher degree of neuronal injury.
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Affiliation(s)
- Prachi Singh
- University of Texas at Southwestern Medical Center - Dallas, Texas, Estados Unidos
| | - Sonia E Stutzman
- University of Texas at Southwestern Medical Center - Dallas, Texas, Estados Unidos
| | | | - DaiWai M Olson
- University of Texas at Southwestern Medical Center - Dallas, Texas, Estados Unidos
| | - Arianna Barnes
- University of Texas at Southwestern Medical Center - Dallas, Texas, Estados Unidos
| | - Folefac D Atem
- University of Texas at Southwestern Medical Center - Dallas, Texas, Estados Unidos
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Cortes MX, Siaron KB, Nadim HT, Ahmed KM, Romito JW. Neurological Pupil Index as an Indicator of Irreversible Cerebral Edema: A Case Series. J Neurosci Nurs 2021; 53:145-148. [PMID: 33782353 DOI: 10.1097/jnn.0000000000000584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: Assessing the pupillary light reflex is a core component of neurological assessments. Pupil size and reactivity can provide early warning about early neurological decline. Automated infrared pupillometry is noninvasive and easy to use and has greater reliability compared with manual assessments to obtain objective and consistent measurements of pupillary size and reactivity to light. METHODS: This is a case series of 3 patients who had poor baseline clinical neurological examinations. Because it would be more difficult to detect acute neurological deterioration, automated infrared pupillometry and the Neurological Pupil index (NPi) were used in addition to the clinical neurological examination. NPi values < 3.0 prompted further imaging. RESULTS: In each case, abnormal NPi values prompted emergent imaging that confirmed acute cerebral edema and resulted in a change in management and treatment plan. CONCLUSION: The automated infrared pupillometry is a noninvasive monitor that can provide additional objective data in patients with a poor baseline neurological examination in whom it may otherwise be difficult to detect neurological deterioration.
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Butt AA, Atem FD, Stutzman SE, Aiyagari V, Venkatachalam AM, Olson DM, Yokobori S. Contribution of pupillary light reflex assessment to Glasgow Coma Scale for prognostication in patients with traumatic brain injury. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Abstract
BACKGROUND Pupillary light reflex (PLR) has traditionally been assessed using a pen torch (light). Although the terms "brisk" or "sluggish" are often used, it is unclear what characteristics of the PLR result in this description. More recently, automated infrared pupillometry has enabled us to quantify the different components of a PLR. METHODS We conducted a 2-part questionnaire survey of pediatric intensive care unit (PICU) nurses. In part 1, nurses were requested to describe the key characteristics that they associate with a brisk or sluggish PLR in free-text responses. In part 2, after an introduction to pupillometry and the different components of a PLR, nurses were asked to rank the relative importance of latency (time taken for pupil to start reacting to light), percentage change (in pupil size after light stimulus), and constriction velocity (rate of constriction after light stimulus) in relation to a pupil being described as "brisk" and "sluggish. RESULTS Fifty nurses responded. In part 1, "Quick" was the commonest term used (36% of respondents) to describe a brisk PLR, and 72% used "slow" for a sluggish PLR. Most descriptions most closely mapped to features of latency and/or constriction velocity. In part 2, latency was ranked the most important component on pupillometry for describing brisk (32%) and sluggish (34%) PLRs. Constriction velocity was ranked as the most important by 18% (brisk) and 20% (sluggish), whereas 44% (brisk) and 46% (sluggish) ranked percentage change behind the other 2 characteristics. CONCLUSION Latency, followed by the constriction velocity, was felt by PICU nurses to be the most important characteristic of the PLR that results in terms "brisk" or "sluggish" being used at the bedside to describe a PLR. We plan to compare these subjective opinions with objective findings from pupillometry.
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Packiasabapathy S, Rangasamy V, Sadhasivam S. Pupillometry in perioperative medicine: a narrative review. Can J Anaesth 2021; 68:566-578. [PMID: 33432497 DOI: 10.1007/s12630-020-01905-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/07/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Pupillometry is a technique for objective quantification of nociception that takes into account the central processing of noxious stimuli and its sympathetic response. This narrative review provides an overview of the physiology of the pupil, the principles of pupillometry, and its potential application in the perioperative environment, especially in nociception monitoring and quantifying responses to opioids. SOURCE Relevant articles, including reports of original investigation, review articles, and meta-analyses were identified from searches of PubMed and Google Scholar databases. Articles that described pupillary physiology and pupillometry, along with original research reports of the application of pupillometry in perioperative and critical care environment were used to synthesize a narrative review. PRINCIPAL FINDINGS Pupillometry is emerging as an objective measure of nociception, especially in patients under general anesthesia, children, non-verbal patients, and critically ill patients who cannot effectively communicate ongoing pain. Portable automated pupillometers have made accurate quantification of pupillary reflexes, including light reflex and dilatation reflex, possible. This technique has been successfully studied in the perioperative setting for a number of applications, including quantification of nociception, response to analgesia, and assessing efficacy of regional blocks. Pupillary oscillations have shown promise in assessing central opioid effects. Pupillometers can also accurately quantify light reflexes during the neurologic evaluation of critically ill patients. CONCLUSIONS Pupillometry is an easy to use non-invasive bedside technique to quantify nociception and monitor opioid effects. It has the potential to personalize pain management in perioperative and intensive care unit environments. Additional studies are needed to further understand the utility of pupillometry in this context.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Valluvan Rangasamy
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA.
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Thakur B, Nadim H, Atem F, Stutzman SE, Olson DM. Dilation velocity is associated with Glasgow Coma Scale scores in patients with brain injury. Brain Inj 2020; 35:114-118. [PMID: 33347373 DOI: 10.1080/02699052.2020.1861481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Pupillary light reflex (PLR) is informative about patients with neurological injury. Automated pupillometry provides discrete variables such as dilation velocity (DV). The objective of this study is to determine association between DV and Glasgow Coma Score (GCS), for patients with acquired brain injury.Methods: There were 2,208 patients with acquired brain injury, pupillometer readings, and daily GCS values available in our registry. GCS was trichotomized as severe (GCS ≤ 8), moderate (GCS = 9-12), or mild injury (GCS = 13-15). Generalized Linear Mixed Model regression was used to identify correlation between DV and GCS.Results: Patient mean age was 58.9 years, and 49.11% were female. There were 42,229 observations of GCS and DV. Mean admission GCS was 11.7. In the left eye, there was a statistically significant negative association for mean DV in patients with mild (DV = 0.85 mm/s), moderate (DV = 0.71 mm/s), and severe (DV = 0.48 mm/s) injury (p < .0001). Similar results were noted in the right eye with mild (DV = 0.87 mm/s), moderate (DV = 0.72 mm/s), and severe (DV = 0.50 mm/s) injury (p < .0001).Conclusion: Higher GCS is associated with faster DV. PLR may provide a biomarker of injury when a neurological exam is limited.Trial Registration: NCT02804438 (June 17, 2016).ABBREVIATIONS: GCS: Glasgow Coma Scale; PLR: Pupillary Light Reflex; DV: Dilation velocity; ICP: Intracranial pressure; NPi: Neurological pupil index; mRS: Modified Rankin Score; PCT: Percent change in size (pre and post constriction); Lat: Latency; CV: Constriction velocity; GLMM: Generalized Linear Mixed Model.
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Affiliation(s)
- Barsha Thakur
- Department of Biostatistics and Data Science, University of Texas at Houston, Houston, Texas, USA
| | - Hend Nadim
- O'Donnell Brain Institute, University of Texas Southwestern, Dallas, Texas, USA
| | - Folefac Atem
- Department of Biostatistics and Data Science, University of Texas at Houston, Houston, Texas, USA
| | - Sonja E Stutzman
- O'Donnell Brain Institute, University of Texas Southwestern, Dallas, Texas, USA.,Department of Neurological Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - DaiWai M Olson
- Department of Biostatistics and Data Science, University of Texas at Houston, Houston, Texas, USA.,Department of Neurology & Neurotherapeutics, University of Texas Southwestern, Dallas, Texas, USA
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Mazhar K, Olson DM, Atem FD, Stutzman SE, Moreno J, Venkatachalam A, Aiyagari V. Supratentorial intracerebral hemorrhage volume and other CT variables predict the neurological pupil index. Clin Neurol Neurosurg 2020; 200:106410. [PMID: 33341651 DOI: 10.1016/j.clineuro.2020.106410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES There is growing interest in the ability of automated infrared pupillometry to assess severity of neurological illness. We studied the correlation between computed tomography (CT) indicators of intracerebral hemorrhage (ICH) severity with objective measures of the pupillary light reflex (PLR), and hypothesized that hemorrhage volume would predict the Neurological Pupil index™ (NPi™), an indicator of pupillary reactivity. METHODS This study examined data from patients with supratentorial ICH who underwent serial pupillometer evaluations. CT images were examined to determine the location and laterality of the hemorrhage, along with hematoma volume (using the simplified ABC/2 method), midline shift, hydrocephalus score, and modified Graeb score (indicating interventricular hemorrhage). Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher's Exact X2, and multivariate modeling with constructed MAX-R models. RESULTS Data were gathered from 44 subjects. ICH volume exhibited the strongest correlation with NPi (ipsilateral [r2 = 0.48, p < 0.0001, contralateral [(r2 = 0.39, p < 0.0001]). Horizontal midline shift of the septum pellucidum also correlated with NPi (ipsilateral [r2 = 0.25, p = 0.0006], contralateral [r2 = 0.15, p = 0.0106]), as did shift of the pineal gland (ipsilateral [r2 = 0.21, p = 0.0017], contralateral[r2 = 0.11, p = 0.0328]). ICH volume was the most predictive of abnormal NPi (AUC = 0.85 for ipsilateral and 0.88 for contralateral NPi), and multivariate modeling identified additional independent predictors of NPi. CONCLUSION ICH volume and shift of midline structures correlate with NPi, and abnormalities in NPi can be predicted by hematoma volume and other CT indicators of ICH severity. Future studies should explore the role of NPi in detecting early hematoma expansion and worsening midline shift.
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Affiliation(s)
- Khadijah Mazhar
- UT Southwestern Medical School, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States; Department of Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Folefac D Atem
- Department of Biostatistics & Data Sciences, University of Texas Health Science Center, 5161 Harry Hines Blvd. CS5.106 Dallas, TX, 75390, United States
| | - Sonja E Stutzman
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - James Moreno
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Aardhra Venkatachalam
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States
| | - Venkatesh Aiyagari
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States; Department of Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States.
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Abstract
BACKGROUND Clinical registries provide insight on the quality of patient care by providing data to identify associations and patterns in diagnosis, disease, and treatment. This has led to a push toward using large data sets in healthcare research. Nurse researchers are developing data registries, but most are unaware of how to manage a data registry. This article examines a neuroscience nursing registry to describe a quality control and data management process. DATA QUALITY PROCESS Our registry contains more than 90 000 rows of data from almost 5000 patients at 4 US hospitals. Data management is a continuous process that consists of 5 phases: screening, data organization, diagnostic, treatment, and missing data. These phases are repeated with each registry update. DISCUSSION The interdisciplinary approach to data management resulted in high-quality data, which was confirmed by missing data analysis. Most technical errors could be systematically diagnosed and resolved using basic statistical outputs, and fixed in the source file. CONCLUSION The methods described provide a structured way for nurses and their collaborators to clean and manage registries.
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El Ahmadieh TY, Bedros N, Stutzman SE, Nyancho D, Venkatachalam AM, MacAllister M, Ban VS, Dahdaleh NS, Aiyagari V, Figueroa S, White JA, Batjer HH, Bagley CA, Olson DM, Aoun SG. Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury. World Neurosurg 2020; 145:e163-e169. [PMID: 33011358 DOI: 10.1016/j.wneu.2020.09.152] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes. METHODS We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied. RESULTS Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n = 4) or ICP monitor placement (n = 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention. CONCLUSIONS AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.
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Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Bedros
- Division of Trauma, Department of Surgery, Baylor University Medical Center, Baylor, Texas, USA
| | - Sonja E Stutzman
- O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel Nyancho
- Department of Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Aardhra M Venkatachalam
- O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew MacAllister
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Vin Shen Ban
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nader S Dahdaleh
- Department of Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Venkatesh Aiyagari
- Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neuro-Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stephen Figueroa
- Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neuro-Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan A White
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - H Hunt Batjer
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos A Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - DaiWai M Olson
- Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Neuro-Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Obinata H, Yokobori S, Shibata Y, Takiguchi T, Nakae R, Igarashi Y, Shigeta K, Matsumoto H, Aiyagari V, Olson DM, Yokota H. Early automated infrared pupillometry is superior to auditory brainstem response in predicting neurological outcome after cardiac arrest. Resuscitation 2020; 154:77-84. [DOI: 10.1016/j.resuscitation.2020.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 12/16/2022]
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