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Vrettou CS, Kominis IK. Letter to the Editor for: "Covert Consciousness in Acute Brain Injury Revealed by Automated Pupillometry and Cognitive Paradigms". Neurocrit Care 2024:10.1007/s12028-024-02023-0. [PMID: 38862710 DOI: 10.1007/s12028-024-02023-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/23/2024] [Indexed: 06/13/2024]
Affiliation(s)
- Charikleia S Vrettou
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676, Athens, Greece.
| | - Iannis K Kominis
- Department of Physics, University of Crete, 70013, Heraklion, Greece
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2
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Brasil S, Chesnut R, Robba C. Noninvasive neuromonitoring in acute brain injured patients. Intensive Care Med 2024; 50:960-963. [PMID: 38630285 DOI: 10.1007/s00134-024-07406-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/19/2024] [Indexed: 06/11/2024]
Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Randall Chesnut
- Department of Neurological Surgery, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104‑2499, USA
- Department of Orthopaedic Surgery, University of Washington, 325 Ninth Ave, Seattle, WA, 98104‑2499, USA
- School of Global Health, University of Washington, 325 Ninth Ave, Seattle, WA, 98104‑2499, USA
- Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA, 98104‑2499, USA
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Policlínico San Martino, Genoa, Italy.
- Dipartimento di Scienze Chirurgiche Diagnostiche e Integrate, University of Genoa, Genoa, Italy.
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3
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Brasil S, Godoy DA, Videtta W, Rubiano AM, Solla D, Taccone FS, Robba C, Rasulo F, Aries M, Smielewski P, Meyfroidt G, Battaglini D, Hirzallah MI, Amorim R, Sampaio G, Moulin F, Deana C, Picetti E, Kolias A, Hutchinson P, Hawryluk GW, Czosnyka M, Panerai RB, Shutter LA, Park S, Rynkowski C, Paranhos J, Silva THS, Malbouisson LMS, Paiva WS. A Comprehensive Perspective on Intracranial Pressure Monitoring and Individualized Management in Neurocritical Care: Results of a Survey with Global Experts. Neurocrit Care 2024:10.1007/s12028-024-02008-z. [PMID: 38811514 DOI: 10.1007/s12028-024-02008-z] [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: 02/23/2024] [Accepted: 05/01/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Numerous trials have addressed intracranial pressure (ICP) management in neurocritical care. However, identifying its harmful thresholds and controlling ICP remain challenging in terms of improving outcomes. Evidence suggests that an individualized approach is necessary for establishing tolerance limits for ICP, incorporating factors such as ICP waveform (ICPW) or pulse morphology along with additional data provided by other invasive (e.g., brain oximetry) and noninvasive monitoring (NIM) methods (e.g., transcranial Doppler, optic nerve sheath diameter ultrasound, and pupillometry). This study aims to assess current ICP monitoring practices among experienced clinicians and explore whether guidelines should incorporate ancillary parameters from NIM and ICPW in future updates. METHODS We conducted a survey among experienced professionals involved in researching and managing patients with severe injury across low-middle-income countries (LMICs) and high-income countries (HICs). We sought their insights on ICP monitoring, particularly focusing on the impact of NIM and ICPW in various clinical scenarios. RESULTS From October to December 2023, 109 professionals from the Americas and Europe participated in the survey, evenly distributed between LMIC and HIC. When ICP ranged from 22 to 25 mm Hg, 62.3% of respondents were open to considering additional information, such as ICPW and other monitoring techniques, before adjusting therapy intensity levels. Moreover, 77% of respondents were inclined to reassess patients with ICP in the 18-22 mm Hg range, potentially escalating therapy intensity levels with the support of ICPW and NIM. Differences emerged between LMIC and HIC participants, with more LMIC respondents preferring arterial blood pressure transducer leveling at the heart and endorsing the use of NIM techniques and ICPW as ancillary information. CONCLUSIONS Experienced clinicians tend to personalize ICP management, emphasizing the importance of considering various monitoring techniques. ICPW and noninvasive techniques, particularly in LMIC settings, warrant further exploration and could potentially enhance individualized patient care. The study suggests updating guidelines to include these additional components for a more personalized approach to ICP management.
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Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil.
| | | | - Walter Videtta
- Intensive Care Unit, Hospital Posadas, Buenos Aires, Argentina
| | | | - Davi Solla
- Division of Neurosurgery, Department of Neurology, School of Medicine University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Chiara Robba
- Anesthesia and Intensive Care, Scientific Institute for Research, Hospitalization and Healthcare, Policlínico San Martino, Genoa, Italy
| | - Frank Rasulo
- Neuroanesthesia, Neurocritical and Postoperative Care, Spedali Civili University Affiliated Hospital of Brescia, Brescia, Italy
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Peter Smielewski
- Department of Clinical Neurosciences, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Denise Battaglini
- Anesthesia and Intensive Care, Scientific Institute for Research, Hospitalization and Healthcare, Policlínico San Martino, Genoa, Italy
| | - Mohammad I Hirzallah
- Departments of Neurology, Neurosurgery, and Center for Space Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Robson Amorim
- Division of Neurosurgery, Department of Neurology, School of Medicine University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Gisele Sampaio
- Neurology Department, São Paulo Federal University Medical School, São Paulo, Brazil
| | - Fabiano Moulin
- Neurology Department, São Paulo Federal University Medical School, São Paulo, Brazil
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | | | | | - Gregory W Hawryluk
- Cleveland Clinic Neurological Institute, Akron General Hospital, Fairlawn, OH, USA
- Uniformed Services University, Bethesda, USA
- Brain Trauma Foundation, New York, USA
| | - Marek Czosnyka
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Ronney B Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Lori A Shutter
- Departments of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Soojin Park
- Departments of Neurology and Biomedical Informatics, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA
| | - Carla Rynkowski
- Department of Urgency and Trauma, Medical Faculty, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Jorge Paranhos
- Intensive Care and Neuroemergency, Santa Casa de Misericórdia, São João del Rei, Brazil
| | - Thiago H S Silva
- Department of Intensive Care, School of Medicine University of São Paulo, São Paulo, Brazil
| | - Luiz M S Malbouisson
- Department of Intensive Care, School of Medicine University of São Paulo, São Paulo, Brazil
| | - Wellingson S Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
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4
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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5
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Ong CJ, Chatzidakis S, Ong JJ, Feske S. Updates in Management of Large Hemispheric Infarct. Semin Neurol 2024. [PMID: 38759959 DOI: 10.1055/s-0044-1787046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
This review delves into updates in management of large hemispheric infarction (LHI), a condition affecting up to 10% of patients with supratentorial strokes. While traditional management paradigms have endured, recent strides in research have revolutionized the approach to acute therapies, monitoring, and treatment. Notably, advancements in triage methodologies and the application of both pharmacological and mechanical abortive procedures have reshaped the acute care trajectory for patients with LHI. Moreover, ongoing endeavors have sought to refine strategies for the optimal surveillance and mitigation of complications, notably space-occupying mass effect, which can ensue in the aftermath of LHI. By amalgamating contemporary guidelines with cutting-edge clinical trial findings, this review offers a comprehensive exploration of the current landscape of acute and ongoing patient care for LHI, illuminating the evolving strategies that underpin effective management in this critical clinical domain.
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Affiliation(s)
- Charlene J Ong
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
| | - Stefanos Chatzidakis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jimmy J Ong
- Department of Neurology, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
- Department of Neurology, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Steven Feske
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
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Gkantsinikoudis N, Monioudis P, Antoniades E, Tsitouras V, Magras I. Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report. Int J Neurosci 2024:1-6. [PMID: 38716712 DOI: 10.1080/00207454.2024.2352767] [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: 02/20/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH). CASE PRESENTATION An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day. CONCLUSION TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.
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Affiliation(s)
- Nikolaos Gkantsinikoudis
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Monioudis
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elias Antoniades
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vassilios Tsitouras
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Magras
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Shi L, Jin DN, Cao XJ, Liu H, Gu WJ, Zhang M, Lu Q. Assessment of sedation by automated pupillometry in critically ill patients: a prospective observational study. Br J Anaesth 2024; 132:877-885. [PMID: 38429209 DOI: 10.1016/j.bja.2024.02.001] [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: 09/11/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Quantitative measurement of pupil change has not been assessed against the Richmond Agitation and Sedation Scale (RASS) and spectral edge frequency (SEF) during sedation. The aim of this study was to evaluate pupillometry against these measures in sedated critically ill adult patients. METHODS In ventilated and sedated patients, pupillary variables were measured by automated pupillometry at each RASS level from -5 to 0 after discontinuation of hypnotics, while processed electroencephalogram variables were displayed continuously and SEF was recorded at each RASS level. Correlations were made between percentage pupillary light reflex (%PLR) and RASS, and between %PLR and SEF. The ability of %PLR to differentiate light sedation (RASS ≥-2), moderate (RASS =-3), and deep sedation (RASS ≤-4) was assessed by areas under receiver operating characteristic (ROC) curves. RESULTS A total of 163 paired measurements were recorded in 38 patients. With decreasing sedation depth, median %PLR increased progressively from 20% (interquartile range 17-25%) to 36% (interquartile range 33-40%) (P<0.001). Strong correlations were found between %PLR and RASS (Rho=0.635) and between %PLR and SEF (R=0.641). Area under the curve (AUC) of 0.87 with a %PLR threshold of 28% differentiated moderate/light sedation from deep sedation with sensitivity of 83% and specificity of 83%. An AUC of 0.82 with a threshold of 31% distinguished light sedation from moderate/deep sedation with a sensitivity of 81% and a specificity of 75%. CONCLUSIONS Quantitative assessment of %PLR correlates with other indicators of sedation depth in critically ill patients.
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Affiliation(s)
- Lin Shi
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Emergency Department, The State Key Laboratory for Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Dan-Ni Jin
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Xia-Jing Cao
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Hong Liu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Wen-Jie Gu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China.
| | - Qin Lu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China.
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Mathur R, Meyfroidt G, Robba C, Stevens RD. Neuromonitoring in the ICU - what, how and why? Curr Opin Crit Care 2024; 30:99-105. [PMID: 38441121 DOI: 10.1097/mcc.0000000000001138] [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: 03/12/2024]
Abstract
PURPOSE OF REVIEW We selectively review emerging noninvasive neuromonitoring techniques and the evidence that supports their use in the ICU setting. The focus is on neuromonitoring research in patients with acute brain injury. RECENT FINDINGS Noninvasive intracranial pressure evaluation with optic nerve sheath diameter measurements, transcranial Doppler waveform analysis, or skull mechanical extensometer waveform recordings have potential safety and resource-intensity advantages when compared to standard invasive monitors, however each of these techniques has limitations. Quantitative electroencephalography can be applied for detection of cerebral ischemia and states of covert consciousness. Near-infrared spectroscopy may be leveraged for cerebral oxygenation and autoregulation computation. Automated quantitative pupillometry and heart rate variability analysis have been shown to have diagnostic and/or prognostic significance in selected subtypes of acute brain injury. Finally, artificial intelligence is likely to transform interpretation and deployment of neuromonitoring paradigms individually and when integrated in multimodal paradigms. SUMMARY The ability to detect brain dysfunction and injury in critically ill patients is being enriched thanks to remarkable advances in neuromonitoring data acquisition and analysis. Studies are needed to validate the accuracy and reliability of these new approaches, and their feasibility and implementation within existing intensive care workflows.
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Affiliation(s)
- Rohan Mathur
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Belgium and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Belgium
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - Robert D Stevens
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore MD, USA
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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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10
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Galimberti S, Petrosino M, Rebora P, Oddo M, Taccone FS, Citerio G. The predictive value and clinical use of the neurological pupillary index - Authors' reply. Lancet Neurol 2024; 23:229-230. [PMID: 38365367 DOI: 10.1016/s1474-4422(23)00504-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/12/2023] [Indexed: 02/18/2024]
Affiliation(s)
- Stefania Galimberti
- School of Medicine and Surgery, University of Milano-Bicocca, Milan 20126, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Matteo Petrosino
- School of Medicine and Surgery, University of Milano-Bicocca, Milan 20126, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano-Bicocca, Milan 20126, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Directorate for Innovation and Clinical Research, CHUV Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan 20126, Italy; Department of Neuroscience, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
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11
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Poon MT, Nouby A, Brennan PM. The predictive value and clinical use of the neurological pupillary index. Lancet Neurol 2024; 23:229. [PMID: 38365366 DOI: 10.1016/s1474-4422(23)00471-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/27/2023] [Indexed: 02/18/2024]
Affiliation(s)
- Michael Tc Poon
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH16 4SB, UK; Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - Ahmed Nouby
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH16 4SB, UK; Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, 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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Banco P, Taccone FS, Sourd D, Privitera C, Bosson JL, Teixeira TL, Adolle A, Payen JF, Bouzat P, Gauss T. Prediction of neurocritical care intensity through automated infrared pupillometry and transcranial doppler in blunt traumatic brain injury: the NOPE study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02435-1. [PMID: 38226989 DOI: 10.1007/s00068-023-02435-1] [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: 09/28/2023] [Accepted: 12/28/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE This pilot study aimed to determine the capacity of automated infrared pupillometry (AIP) alone and in combination with transcranial doppler (TCD) on admission to rule out need for intense neuroAQ2 critical care (INCC) in severe traumatic brain injury (TBI). METHODS In this observational pilot study clinicians performed AIP and TCD measurements on admission in blunt TBI patients with a Glasgow Coma Score (GCS) < 9 and/or motor score < 6. A Neurological Pupil index (NPi) < 3, Pulsatility Index (PI) > 1,4 or diastolic blood flow velocity (dV) of < 20 cm/s were used to rule out the need for INCC (exceeding the tier 0 Seattle Consensus Conference). The primary outcome was the negative likelihood ratio (nLR) of NPi < 3 alone or in combination with TCD to detect need for INCC. RESULTS A total of 69 TBI patients were included from May 2019 to September 2020. Of those, 52/69 (75%) median age was 45 [28-67], median prehospital GCS of 7 [5-8], median Injury Severity Scale of 13.0 [6.5-25.5], median Marshall Score of 4 [3-5], the median Glasgow Outcome Scale at discharge was 3 [1-5]. NPi < 3 was an independent predictor of INCC. NPi demonstrated a nLR of 0,6 (95%CI 0.4-0.9; AUROC, 0.65, 95% CI 0.51-0.79), a combination of NPi and TCD showed a nLR of 0.6 (95% CI 0.4-1.0; AUROC 0.67 95% CI 0.52-0.83) to predict INCC. CONCLUSION This pilot study suggests a possible useful contribution of NPi to determine the need for INCC in severe blunt TBI patients on admission.
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Affiliation(s)
- Pierluigi Banco
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Dimitri Sourd
- Department of Public Health, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Claudio Privitera
- School of Optometry and Vision Science, University of California, Berkeley, Berkeley, CA, USA
| | - Jean-Luc Bosson
- Department of Public Health, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Thomas Luz Teixeira
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Anais Adolle
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France
| | - Jean-François Payen
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France
| | - Pierre Bouzat
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France
| | - Tobias Gauss
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble, and Inserm, U1216, Grenoble Institut Neurosciences, 38000, Grenoble, France.
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Ong CJ. The prognostic potential of pupillometry in patients with acute brain injury. Lancet Neurol 2023; 22:876-878. [PMID: 37652069 PMCID: PMC10791071 DOI: 10.1016/s1474-4422(23)00314-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Charlene J Ong
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA.
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