Automated Pupillometry Value Differences Serve as a Prognostic Indicator Even When They are Within Normal Range
DOI:
https://doi.org/10.15225/PNN.2021.10.4.5Keywords
Glasgow Coma Scale (GCS), Neurological Pupil index (NPi), NPi Difference, pupillary light reflex (PLR), pupillometryAbstract
Introduction. The pupillary light reflex (PLR) is an integral aspect of the neurologic exam. With the enhancement of automated infrared pupillometry (AIP), the Neurological Pupil index (NPi) is being increasingly used when performing a neurological examination. NPi difference (the absolute difference between paired NPi readings from the left and right eye) is a relatively unexplored variable in AIP assessment.
Aim. This study evaluates the association between Glasgow Coma Scale (GCS) scores and NPi differences between the left and right eyes, when the NPi is normal, in patients enrolled in a multi-center prospective database.
Material and Methods. Restricting observations to only include NPi values ≥ 3 (normal), there were 2,572 qualifying patients with 3,519 pupillometer readings linked to GCS values. Linear regression and ANOVA models were developed to investigate the relationship between GCS and NPi difference.
Results. Subject mean age was 55.88 (16.95) years and 54.5% were female. Mean NPi difference was 0.36 and mean GCS was 12.06. Regression analysis indicated a slight negative association between NPi difference and GCS (r2 = 0.0696, P < .0001). When observations were dichotomized as either NPi difference ≥ 0.7 (large) or < 0.7 (small), there was a statistically significant difference in the mean GCS (10.76 [3.90]) for large NPi difference vs. small NPi difference (13.15 [2.68]; P < .0001).
Conclusions. Even among patients with normal PLR, a large NPi difference is associated with lower GCS scores. Trending and evaluating the NPi difference may become an important aspect of patient assessment. (JNNN 2021;10(4):168–174)
References
Olson D.M., Stutzman S.E., Atem F. et al. Establishing Normative Data for Pupillometer Assessment in Neuroscience Intensive Care: The “END-PANIC” Registry. J Neurosci Nurs. 2017;49(4):251–254.
Lussier B.L., Stutzman S.E., Atem F. et al. Distributions and Reference Ranges for Automated Pupillometer Values in Neurocritical Care Patients. J Neurosci Nurs. 2019;51(6):335–340.
Chen J.W., Gombart Z.J., Rogers S., Gardiner S.K., Cecil S., Bullock R.M. Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index. Surg Neurol Int. 2011;2:82.
Lussier B.L., Olson D.M., Aiyagari V. Automated Pupillometry in Neurocritical Care: Research and Practice. Curr Neurol Neurosci Rep. 2019;19(10):71.
Shoyombo I., Aiyagari V., Stutzman S.E. et al. Understanding the Relationship Between the Neurologic Pupil Index and Constriction Velocity Values. Sci Rep. 2018;8(1):6992.
Meeker M., Du R., Bacchetti P. et al. Pupil examination: validity and clinical utility of an automated pupillometer. J Neurosci Nurs. 2005;37(1):34–40.
Hall C.A., Chilcott R.P. Eyeing up the Future of the Pupillary Light Reflex in Neurodiagnostics. Diagnostics (Basel). 2018;8(1):19.
Cortes M.X., Siaron K.B., Nadim H.T., Ahmed K.M., Romito J.W. Neurological Pupil Index as an Indicator of Irreversible Cerebral Edema: A Case Series. J Neurosci Nurs. 2021;53(3):145–148.
Oddo M., Sandroni C., Citerio G. et al. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study. Intensive Care Med. 2018;44(12):2102–2111.
Natzeder S., Mack D.J., Maissen G., Strässle C., Keller E., Muroi C. Portable Infrared Pupillometer in Patients With Subarachnoid Hemorrhage: Prognostic Value and Circadian Rhythm of the Neurological Pupil Index (NPi). J Neurosurg Anesthesiol. 2019;31(4):428–433.
McNett M.M., Amato S., Philippbar S.A. A Comparative Study of Glasgow Coma Scale and Full Outline of Unresponsiveness Scores for Predicting Long-Term Outcome After Brain Injury. J Neurosci Nurs. 2016;48(4):207–214.
Thakur B., Nadim H., Atem F., Stutzman S.E., Olson D.M. Dilation velocity is associated with Glasgow Coma Scale scores in patients with brain injury. Brain Inj. 2021;35(1):114–118.
Minami Y., Mishima S., Oda J. Prediction of the level of consciousness using pupillometer measurements in patients with impaired consciousness brought to the emergency and critical care center. Acute Med Surg. 2020;7(1):e537.
McNett M., Moran C., Janki C., Gianakis A. Correlations Between Hourly Pupillometer Readings and Intracranial Pressure Values. J Neurosci Nurs. 2017;49(4):229–234.
Teasdale G., Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81–84.
Majdan M., Steyerberg E.W., Nieboer D., Mauritz W., Rusnak M., Lingsma H.F. Glasgow coma scale motor score and pupillary reaction to predict six-month mortality in patients with traumatic brain injury: comparison of field and admission assessment. J Neurotrauma. 2015;32(2):101–108.
Leitgeb J., Mauritz W., Brazinova A. et al. Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury. Eur J Trauma Emerg Surg. 2013;39(3):285–292.
Brennan P.M., Murray G.D., Teasdale G.M. Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity. J Neurosurg. 2018;128(6):1612–1620.
Obling L., Hassager C., Illum C. et al. Prognostic value of automated pupillometry: an unselected cohort from a cardiac intensive care unit. Eur Heart J Acute Cardiovasc Care. 2020;9(7):779–787.
Aoun S.G., Stutzman S.E., Vo P.N. et al. Detection of delayed cerebral ischemia using objective pupillometry in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg. 2019;132(1):27–32.
Papangelou A., Zink E.K., Chang W.W. et al. Automated Pupillometry and Detection of Clinical Transtentorial Brain Herniation: A Case Series. Mil Med. 2018;183(1–2):e113–e121.
El Ahmadieh T.Y., Bedros N., Stutzman S.E. et al. Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury. World Neurosurg. 2021;145:e163–e169.
Dance S., Scholefield B.R., Morris K.P., Kanthimathinathan H.K. Characteristics of a Brisk or Sluggish Pupillary Light Reflex: A Nursing Perspective. J Neurosci Nurs. 2020;52(3):128–131.
Al-Obaidi S.Z., Atem F.D., Stutzman S.E., Olson D.M. Impact of Increased Intracranial Pressure on Pupillometry: A Replication Study. Crit Care Explor. 2019;1(10):e0054.
Osman M., Stutzman S.E., Atem F. et al. Correlation of Objective Pupillometry to Midline Shift in Acute Stroke Patients. J Stroke Cerebrovasc Dis. 2019;28(7):1902–1910.
Kim T.J., Park S.H., Jeong H.B. et al. Neurological Pupil Index as an Indicator of Neurological Worsening in Large Hemispheric Strokes. Neurocrit Care. 2020;33(2):575–581.
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Stats
Number of views and downloads: 436
Number of citations: 0