Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

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Abstract

Background

Elevated intracranial pressure (ICP) is frequent after traumatic brain injury (TBI) and may cause abnormal pupillary reactivity, which in turn is associated with a worse prognosis. Using automated infrared pupillometry, we examined the relationship between the Neurological Pupil index (NPi) and invasive ICP in patients with severe TBI.

Methods

This was an observational cohort of consecutive subjects with severe TBI (Glasgow Coma Scale [GCS] < 9 with abnormal lesions on head CT) who underwent parenchymal ICP monitoring and repeated NPi assessment with the NPi-200® pupillometer. We examined NPi trends over time (four consecutive measurements over intervals of 6 h) prior to sustained elevated ICP > 20 mmHg. We further analyzed the relationship of cumulative abnormal NPi burden (%NPi values < 3 during total ICP monitoring time) with intracranial hypertension (ICHT)—categorized as refractory (ICHT-r; requiring surgical decompression) vs. non-refractory (ICHT-nr; responsive to medical therapy)—and with the 6-month Glasgow Outcome Score (GOS).

Results

A total of 54 patients were studied (mean age 54 ± 21 years, 74% with focal injuries on CT), of whom 32 (59%) had ICHT. Among subjects with ICHT, episodes of sustained elevated ICP ( n = 43, 172 matched ICP-NPi samples; baseline ICP [T _− 6 h] 14 ± 5 mmHg vs. ICPmax [T _0 h] 30 ± 9 mmHg) were associated with a concomitant decrease of the NPi (baseline 4.2 ± 0.5 vs. 2.8 ± 1.6, p < 0.0001 ANOVA for repeated measures). Abnormal NPi values were more frequent in patients with ICHT-r ( n = 17; 38 [3–96]% of monitored time vs. 1 [0–9]% in patients with ICHT-nr [ n = 15] and 0.5 [0–10]% in those without ICHT [ n = 22]; p = 0.007) and were associated with an unfavorable 6-month outcome (15 [1–80]% in GOS 1–3 vs. 0 [0–7]% in GOS 4–5 patients; p = 0.002).

Conclusions

In a selected cohort of severe TBI patients with abnormal head CT lesions and predominantly focal cerebral injury, elevated ICP episodes correlated with a concomitant decrease of NPi. Sustained abnormal NPi was in turn associated with a more complicated ICP course and worse outcome.

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Most cited references 25

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Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.

Nancy Carney, Annette Totten, Cindy OʼReilly … (2016)

The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.

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Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index

Jeff W Chen, Zoe Gombart, Shana Rogers … (2011)

Background This paper introduces the 7/5/2011al Pupil index (NPi), a sensitive measure of pupil reactivity and an early indicator of increasing intracranial pressure (ICP). This may occur in patients with severe traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage (ICH). Methods 134 patients (mean age 46 years, range 18–87 years, 54 women and 80 men) in the intensive care units at eight different clinical sites were enrolled in the study. Pupillary examination was performed using a portable hand-held pupillometer. Results Patients with abnormal pupillary light reactivity had an average peak ICP of 30.5 mmHg versus 19.6 mmHg for the normal pupil reactivity population (P = 0.0014). Patients with “nonreactive pupils” had the highest peaks of ICP (mean = 33.8 mmHg, P = 0.0046). In the group of patients with abnormal pupillary reactivity, we found that the first evidence of pupil abnormality occurred, on average, 15.9 hours prior to the time of the peak of ICP. Conclusions Automated pupillary assessment was used in patients with possible increased ICP. Using NPi, we were able to identify a trend of inverse relationship between decreasing pupil reactivity and increasing ICP. Quantitative measurement and classification of pupillary reactivity using NPi may be a useful tool in the early management of patients with causes of increased ICP.

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Optic nerve sheath diameter measured sonographically as non-invasive estimator of intracranial pressure: a systematic review and meta-analysis

Chiara Robba, Gregorio Santori, Marek Czosnyka … (2018)

Although invasive intracranial devices (IIDs) are the gold standard for intracranial pressure (ICP) measurement, ultrasonography of the optic nerve sheath diameter (ONSD) has been suggested as a potential non-invasive ICP estimator. We performed a meta-analysis to evaluate the diagnostic accuracy of sonographic ONSD measurement for assessment of intracranial hypertension (IH) in adult patients.

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Author and article information

Contributors

Fritz-Patrick Jahns: Fritz-Patrick.Jahns@chuv.ch

John Paul Miroz: John-Paul.Miroz@chuv.ch

Mahmoud Messerer: Mahmoud.Messerer@chuv.ch

Roy T. Daniel: Roy.Daniel@chuv.ch

Fabio Silvio Taccone: ftaccone@ulb.ac.be

Philippe Eckert: Philippe.Eckert@chuv.ch

Mauro Oddo:

ORCID: http://orcid.org/0000-0002-6155-2525

Mauro.Oddo@chuv.ch

Journal

Journal ID (nlm-ta): Crit Care

Title: Critical Care

Publisher: BioMed Central (London )

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Electronic): 2 May 2019

Publication date PMC-release: 2 May 2019

Publication date Collection: 2019

Volume: 23

Electronic Location Identifier: 155

Affiliations

[1 ]ISNI 0000 0001 2165 4204, GRID grid.9851.5, Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Faculty of Biology and Medicine, , University of Lausanne, ; Rue du Bugnon 46, BH 08.623, CH-1011 Lausanne, Switzerland

[2 ]ISNI 0000 0001 2165 4204, GRID grid.9851.5, Critical Care Clinical Research Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Faculty of Biology and Medicine, , University of Lausanne, ; 1011 Lausanne, Switzerland

[3 ]ISNI 0000 0001 0423 4662, GRID grid.8515.9, Department of Clinical Neurosciences, Neurosurgery Service, Centre Hospitalier Universitaire Vaudois (CHUV), Faculty of Biology and Medicine, , Lausanne University Hospital, ; 1011 Lausanne, Switzerland

[4 ]ISNI 0000 0000 8571 829X, GRID grid.412157.4, Department of Intensive Care Medicine, , Erasme University Hospital, ; Brussels, Belgium

Author information

Mauro Oddo http://orcid.org/0000-0002-6155-2525

Article

Publisher ID: 2436

DOI: 10.1186/s13054-019-2436-3

PMC ID: 6498599

PubMed ID: 31046817

SO-VID: 4593ce51-2313-41a4-8973-3327badfcc25

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 6 February 2019

Date accepted : 12 April 2019

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: traumatic brain injury,pupillometry,pupillary reactivity,neurological pupil index,intracranial pressure,intracranial hypertension,outcome,prognosis

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: traumatic brain injury, pupillometry, pupillary reactivity, neurological pupil index, intracranial pressure, intracranial hypertension, outcome, prognosis

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

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Irish Journal of Paramedicine

Most cited references 25

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.

Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index

Optic nerve sheath diameter measured sonographically as non-invasive estimator of intracranial pressure: a systematic review and meta-analysis

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