Can Quantitative Pupillometry be used to Screen for Elevated Intracranial Pressure? A Retrospective Cohort Study

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Abstract

Background

Elevated intracranial pressure (ICP) is a serious complication in brain injury. Because of the risks involved, ICP is not monitored in all patients at risk. Noninvasive screening tools to identify patients with elevated ICP are needed. Anisocoria, abnormal pupillary size, and abnormal pupillary light reflex are signs of high ICP, but manual pupillometry is arbitrary and subject to interrater variability. We have evaluated quantitative pupillometry as a screening tool for elevated ICP.

Methods

We performed a retrospective observational study of the association between Neurological Pupil index (NPi), measured with the Neuroptics NPi-200 pupillometer, and ICP in patients routinely monitored with invasive ICP measurement in the intensive care unit. We performed a nonparametric receiver operator curve analysis for ICP ≥ 20 mm Hg with NPi as a classification variable. We performed a Youden analysis for the optimal NPi cutoff value and recorded sensitivity and specificity for this cutoff value. We also performed a logistic regression with elevated ICP as the dependent variable and NPi as the independent variable.

Results

We included 65 patients with invasive ICP monitoring. A total of 2,705 measurements were analyzed. Using NPi as a screening tool for elevated ICP yielded an area under receiver operator curve of 0.72. The optimal mean NPi cutoff value to rule out elevated ICP was ≥ 3.9. The probability of elevated ICP decreased with increasing NPi, with an odds ratio of 0.55 (0.50, 0.61).

Conclusions

Screening with NPi may inform high stakes clinical decisions by ruling out elevated ICP with a high degree of certainty. It may also aid in estimating probabilities of elevated ICP. This can help to weigh the risks of initiating invasive ICP monitoring against the risks of not doing so. Because of its ease of use and excellent interrater reliability, we suggest further studies of NPi as a screening tool for elevated ICP.

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Most cited references 17

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Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study

David Couret, Delphine Boumaza, Coline Grisotto … (2016)

Background In critical care units, pupil examination is an important clinical parameter for patient monitoring. Current practice is to use a penlight to observe the pupillary light reflex. The result seems to be a subjective measurement, with low precision and reproducibility. Several quantitative pupillometer devices are now available, although their use is primarily restricted to the research setting. To assess whether adoption of these technologies would benefit the clinic, we compared automated quantitative pupillometry with the standard clinical pupillary examination currently used for brain-injured patients. Methods In order to determine inter-observer agreement of the device, we performed repetitive measurements in 200 healthy volunteers ranging in age from 21 to 58 years, providing a total of 400 paired (alternative right eye, left eye) measurements under a wide variety of ambient light condition with NeuroLight Algiscan pupillometer. During another period, we conducted a prospective, observational, double-blinded study in two neurocritical care units. Patients admitted to these units after an acute brain injury were included. Initially, nursing staff measured pupil size, anisocoria and pupillary light reflex. A blinded physician subsequently performed measurement using an automated pupillometer. Results In 200 healthy volunteers, intra-class correlation coefficient for maximum resting pupil size was 0.95 (IC: 0.93-0.97) and for minimum pupil size after light stimulation 0.87 (0.83–0.89). We found only 3-pupil asymmetry (≥1 mm) in these volunteers (1.5 % of the population) with a clear pupil asymmetry during clinical inspection. The mean pupil light reactivity was 40 ± 7 %. In 59 patients, 406 pupillary measurements were prospectively performed. Concordance between measurements for pupil size collected using the pupillometer, versus subjective assessment, was poor (Spearmen's rho = 0.75, IC: 0.70-0.79; P < 0.001). Nursing staff failed to diagnose half of the cases (15/30) of anisocoria detected using the pupillometer device. A global rate of discordance of 18 % (72/406) was found between the two techniques when assessing the pupillary light reflex. For measurements with small pupils (diameters <2 mm) the error rate was 39 % (24/61). Conclusion Standard practice in pupillary monitoring yields inaccurate data. Automated quantitative pupillometry is a more reliable method with which to collect pupillary measurements at the bedside. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1239-z) contains supplementary material, which is available to authorized users.

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Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review

Chiara Robba, Alberto Goffi, Thomas Geeraerts … (2019)

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Intracranial pressure monitoring: Gold standard and recent innovations

Deb Nag, Seelora Sahu, Amlan Swain … (2019)

Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate non-invasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortion-product oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.

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Author and article information

Contributors

Jakob Pansell:

ORCID: http://orcid.org/0000-0002-6665-0589

jakob.pansell@regionstockholm.se

Journal

Journal ID (nlm-ta): Neurocrit Care

Journal ID (iso-abbrev): Neurocrit Care

Title: Neurocritical Care

Publisher: Springer US (New York )

ISSN (Print): 1541-6933

ISSN (Electronic): 1556-0961

Publication date (Electronic): 23 May 2022

Publication date PMC-release: 23 May 2022

Publication date (Print): 2022

Volume: 37

Issue: 2

Pages: 531-537

Affiliations

[1 ]GRID grid.4714.6, ISNI 0000 0004 1937 0626, Department of Clinical Neuroscience, , Karolinska Institutet, ; Central Intensive Care Unit E5:67, Karolinska University Hospital, Stockholm, 17176 Sweden

[2 ]GRID grid.4714.6, ISNI 0000 0004 1937 0626, Department of Anesthesia and Intensive Care Medicine, , Karolinska Institutet, ; Central Intensive Care Unit E5:67, Karolinska University Hospital, Stockholm, 17176 Sweden

[3 ]GRID grid.4714.6, ISNI 0000 0004 1937 0626, Department of Physiology & Pharmacology, , Karolinska Institutet, ; Stockholm, Sweden

[4 ]GRID grid.24381.3c, ISNI 0000 0000 9241 5705, The Department of Clinical Neurophysiology, , Karolinska University Hospital, ; Stockholm, Sweden

Author information

Jakob Pansell http://orcid.org/0000-0002-6665-0589

Article

Publisher ID: 1518

DOI: 10.1007/s12028-022-01518-y

PMC ID: 9519702

PubMed ID: 35606562

SO-VID: da26720c-b0ca-4727-8534-5d09fd674be6

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 30 January 2022

Date accepted : 11 April 2022

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100004348, Stockholms Läns Landsting;

Award ID: SLL20200100

Award Recipient : Jakob Pansell

Funded by: Karolinska Institute

Open Access :

Open access funding provided by Karolinska Institute.

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issue-copyright-statement © Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2022

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: intracranial pressure,quantitative pupillometry,brain injuries,neurology,neurosurgery,critical care,stroke,cardiac arrest,brain edema,cerebral edema,intensive care

Data availability:

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: intracranial pressure, quantitative pupillometry, brain injuries, neurology, neurosurgery, critical care, stroke, cardiac arrest, brain edema, cerebral edema, intensive care

Can Quantitative Pupillometry be used to Screen for Elevated Intracranial Pressure? A Retrospective Cohort Study

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Preventive and Emergency Medicine Insights

Most cited references 17

Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study

Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review

Intracranial pressure monitoring: Gold standard and recent innovations

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