Pupillary Reaction Research Articles

Teaching NeuroImages: Thermal imaging in Horner syndrome

A 50-year-old woman with a history of fibromuscular dysplasia presented to the emergency department with 1 day of right ear pain. Examination demonstrated 2 mm anisocoria, left pupil larger than right, with brisk pupillary light reactions bilaterally; 2.5 mm right ptosis; and anhidrosis of the right forehead, as determined by the spoon test. Thermal imaging was consistent with this finding (figure). She was diagnosed with acute, painful Horner syndrome. MRI/magnetic resonance angiography demonstrated right internal carotid artery dissection. Due to the risk of stroke immediately following internal carotid dissection,1 she was treated with heparin drip, then later transitioned to aspirin and clopidogrel therapy.2

Long-Term Ophthalmic Outcomes in Pediatric Orbital Cellulitis: A Prospective, Multidisciplinary Study From a Tertiary-Care Referral Institute

To analyze the clinical profile, radiological features, and ophthalmic outcomes of the multidisciplinary management of children with pediatric orbital cellulitis. A prospective, interventional study of patients diagnosed as having pediatric orbital cellulitis was conducted. A complete history, clinical examination, laboratory work-up, radiology (computed tomography [CT]), multidisciplinary consultations (otolaryngology, pediatrics, and microbiology), and treatment plan were obtained for all children. The patients were admitted to the hospital and administered intravenous broad-spectrum antibiotics. Orbital and subperiosteal abscesses were drained via an endonasal or external route. Functional endoscopic sinus surgery was performed when necessary. After a minimum follow-up of 12 months, visual acuity, pupillary reaction, extraocular movements, and proptosis were evaluated as the outcome measures. Forty patients (male = 28, 70%) had unilateral presentation of pediatric orbital cellulitis at a mean age of 7.5 years (range: 4 to 12 years). At presentation, all patients had eyelid edema, conjunctival congestion, and chemosis: 38 (95%) had proptosis, 36 (90%) had decreased extraocular movements and pain, 16 (40%) had a relative afferent pupillary defect, and 6 (15%) had exposure keratitis and optic disc edema. CT scans showed sinusitis in 30 (75%) patients, orbital abscess in 14 (35%) patients, and subperiosteal abscess in 5 (12.5%) patients. At a mean follow-up of 15 months, 30 (75%) patients had complete success, 8 (20%) patients had partial success, and the treatment failed in 2 (5%) patients. No patient had any life-threatening complications. The multidisciplinary management of pediatric orbital cellulitis provides satisfactory long-term ophthalmic outcomes. Ethmoidal sinusitis is the most common etiology of pediatric orbital cellulitis, and endoscopic abscess drainage and functional endoscopic sinus surgery are minimally invasive and provide rapid relief in children. [J Pediatr Ophthalmol Strabismus. 2019;56(5):333-339.].

CHANGES IN BINOCULAR PUPILLOMETRY IN ATHLETES AFTER HIGH EXERCISE STRESS

Aim. The article deals with studying the changes in binocular pupillometry to establish vegetative activity in athletes after high exercise stress. Materials and methods. 25 male athletes aged 19–34 years with no health limitations participated in the study. We estimated a set of the commonly accepted parameters of pupillometry (pupil diameter, pupil reaction initiation time, pupil constriction diameter, pupil constriction velocity) by measuring pupil reaction to a light stimulus with the help of a non-contact pupilometer (KVAZAR, Moscow). The examination was conducted prior to physical stress and 5, 15, and 30 minutes after. Intertrack-750 treadmill (SchillerAG, Switzerland) was used for testing. Results. The results obtained in a pupillometric study prove that there is a predominance of the sympathetic component in athletes at maximal load accompanied by emotional stress. After physical stress accompanied by fatigue and nervous system exhaustion, there is a pronounced predominance of the parasympathetic component. Conclusion. The data obtained prove that binocular pupillometry can be effectively used in sports medicine to estimate vegetative tone and regulatory mechanisms in athletes.

Central Sensitization, N-methyl-D-aspartate Receptors, and Human Experimental Pain Models: Bridging the Gap between Target Discovery and Drug Development.

Central Sensitization, N-methyl-D-aspartate Receptors, and Human Experimental Pain Models: Bridging the Gap between Target Discovery and Drug Development.

A clinical decision rule to predict intracranial hypertension in severe traumatic brain injury.

While existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension. Using Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT). The final predictors and the clinical decision rule were approved by 97% of participants in the consensus working group. The predictors are divided into major and minor criteria. High ICP would be considered suspected in the presence of 1 major or ≥ 2 minor criteria. Major criteria are: compressed cisterns (CT classification of Marshall diffuse injury [DI] III), midline shift > 5 mm (Marshall DI IV), or nonevacuated mass lesion. Minor criteria are: Glasgow Coma Scale (GCS) motor score ≤ 4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall DI II. The area under the curve for the logistic regression model that contains all the predictors was 0.86. When high ICP was defined as > 22 mm Hg, the decision rule performed with a sensitivity of 93.9% (95% CI 85.0%-98.3%), a specificity of 42.3% (95% CI 31.7%-53.6%), a positive predictive value of 55.5% (95% CI 50.7%-60.2%), and a negative predictive value of 90% (95% CI 77.1%-96.0%). The sensitivity of the clinical decision rule improved with higher ICP cutoffs up to a sensitivity of 100% when intracranial hypertension was defined as ICP > 30 mm Hg. Similar results were found in the North American cohort. A simple clinical decision rule based on a combination of clinical and imaging findings was found to be highly sensitive in distinguishing patients with severe TBI who would suffer intracranial hypertension. It could be used to identify patients who require ICP monitoring in high-resource settings or start ICP-lowering treatment in environments where resource limitations preclude invasive monitoring.Clinical trial registration no.: NCT02059941 (clinicaltrials.gov).

Pupil reactivity to emotional faces among convicted violent offenders: The role of psychopathic traits.

Psychopathy is characteristically associated with impairments in recognizing others' facial expressions of emotion, and there is some evidence that these difficulties are specific to the callousness features of the disorder. However, it remains unclear whether these difficulties are accompanied by reductions in autonomic reactivity when viewing others' emotional expressions, and whether these impairments are particular to expressions showing another's distress or are more pervasive across different emotional expressions. In this study, 73 adult male prisoners with histories of serious sexual or violent offenses-who ranged across the psychopathy continuum-completed a facial emotion recognition task. For the first time in a convicted offender sample, we used pupillometry techniques to measure changes in the pupil dilation response, a measure of sympathetic autonomic arousal to affective stimuli. We found that the callousness features of psychopathy were related to impaired recognition of fearful faces. Strikingly, we also showed that increasing callousness was associated with a reduction in the pupil dilation response and that this was pervasive across different emotional expressions. Our results highlight a potential role of the locus coeruleus-noradrenaline system in the pathophysiology of psychopathy and demonstrate the potential of the pupillary response as a technique for understanding attention-emotion interactions in psychopathy. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The functional neuroanatomy of emotion processing in frontotemporal dementias.

Impaired processing of emotional signals is a core feature of frontotemporal dementia syndromes, but the underlying neural mechanisms have proved challenging to characterize and measure. Progress in this field may depend on detecting functional changes in the working brain, and disentangling components of emotion processing that include sensory decoding, emotion categorization and emotional contagion. We addressed this using functional MRI of naturalistic, dynamic facial emotion processing with concurrent indices of autonomic arousal, in a cohort of patients representing all major frontotemporal dementia syndromes relative to healthy age-matched individuals. Seventeen patients with behavioural variant frontotemporal dementia [four female; mean (standard deviation) age 64.8 (6.8) years], 12 with semantic variant primary progressive aphasia [four female; 66.9 (7.0) years], nine with non-fluent variant primary progressive aphasia [five female; 67.4 (8.1) years] and 22 healthy controls [12 female; 68.6 (6.8) years] passively viewed videos of universal facial expressions during functional MRI acquisition, with simultaneous heart rate and pupillometric recordings; emotion identification accuracy was assessed in a post-scan behavioural task. Relative to healthy controls, patient groups showed significant impairments (analysis of variance models, all P < 0.05) of facial emotion identification (all syndromes) and cardiac (all syndromes) and pupillary (non-fluent variant only) reactivity. Group-level functional neuroanatomical changes were assessed using statistical parametric mapping, thresholded at P < 0.05 after correction for multiple comparisons over the whole brain or within pre-specified regions of interest. In response to viewing facial expressions, all participant groups showed comparable activation of primary visual cortex while patient groups showed differential hypo-activation of fusiform and posterior temporo-occipital junctional cortices. Bi-hemispheric, syndrome-specific activations predicting facial emotion identification performance were identified (behavioural variant, anterior insula and caudate; semantic variant, anterior temporal cortex; non-fluent variant, frontal operculum). The semantic and non-fluent variant groups additionally showed complex profiles of central parasympathetic and sympathetic autonomic involvement that overlapped signatures of emotional visual and categorization processing and extended (in the non-fluent group) to brainstem effector pathways. These findings open a window on the functional cerebral mechanisms underpinning complex socio-emotional phenotypes of frontotemporal dementia, with implications for novel physiological biomarker development.

Factors Affecting Pupil Reactivity After Cycloplegia in Asian Children.

Purpose:The aim of this study was to evaluate the factors affecting cycloplegia, as determined by pupil reactivity, in Asian children.Design:Prospective observational study.Methods:Two-hundred sixty-eight children, aged 2 to 12 years, requiring cycloplegic refraction, were recruited. Nurses instilled 2 to 3 cycles of eye drops consisting of cyclopentolate 1%, tropicamide 0.5%, and phenylephrine 2.5%, and recorded the child's level of cooperation. Optometrists recorded pupil reactivity after the last cycle. Multivariate analysis determined factors affecting pupil reactivity including age, sex, race, number of eye drop cycles, pupil sizes before and after cycloplegia, and child's cooperation during eye drops instillation.Results:The pupils in 36 children (13.4%) were found to be still reactive. On univariate analysis, children with reactive pupils also had smaller pupils after cycloplegia (6.27 ± 1.16 mm vs 7.42 ± 0.81 mm, P < 0.001). On multiple logistic regression analysis, for every 1-mm increase in the pupil size after cycloplegic eye drop administration, the odds of having reactive pupils decreases by 65% (odds ratio = 0.35, 95% confidence interval 0.25–0.51, P ≤ 0.001). Those who were uncooperative during administration of eye drops were 3.13 times more likely to have reactive pupils (95% confidence interval 1.21–8.13, P = 0.019), whereas age (P = 0.904), sex (P = 0.355), the number of cycles of eye drops (P = 0.462), and other psychological factors were not relevant in affecting pupil reactivity.Conclusions:Pupil reactivity, which was used as a measure of cycloplegia, was more likely to be affected by children's level of cooperation during instillation of eye drops, rather than age and sex. Two cycles of eye drops were as effective as 3 cycles in producing cycloplegia.

Decompressive craniectomy for severe traumatic brain injury in children: analysis of long-term neuropsychological impairment and review of the literature.

The effectiveness of decompressive craniectomy (DC) in the context of neurocritical care in adult patients has been recently under debate. The aim of our study was to evaluate the impact of decompressive craniectomy in severe traumatic brain injury (TBI) in children, focusing on short and long-term neurological and neuropsychological outcomes. Retrospective review of the medical records of children admitted at a level I trauma center, between January 2012 and December 2015, submitted to DC due to severe TBI. Additionally, an extensive review of literature on this subject was carried out. Sixteen patients underwent DC for TBI at our institution during the evaluated period. 62.5% were males and the mean age was 12years. Road traffic accident (RTA) was the main mechanism of trauma (62.5%). Average Glasgow Coma Scale (GCS) at admission was 5.2, whereas 75% of the patients presented with pathological pupillary reaction. Initial computed tomography (CT) showed skull fractures in 62.5% and acute subdural hemorrhage (ASH) in 56.3% of the patients. The mean intracranial pressure (ICP) was 27.2mmHg prior to surgery, and the mean time window between admission and DC was 36.3h. Unilateral DC was performed in 68.8% of the cases. The average Glasgow Outcome Scale (GOS) at 6-month follow-up was 3.7, whereas 70% of the survivors presented good recovery (GOS 4-5). Abnormal pupillary reaction at hospital admission increased 3-fold the risk of long-term neuropsychological disturbances. Follow-up evaluation revealed cognitive abnormality in 55.6% of the patients. The overall mortality at 6-month follow-up was 37.5%. The present study indicates towards a potential benefit of DC in children with severe TBI; nevertheless, our data demonstrated a high incidence of neuropsychological impairment in the long-term follow-up. Psychological and cognitive assessment should be computed in prognosis evaluation in future prospective studies.

The relation of skin conductance and pupillary fluctuations assessed by phase-rectified signal averaging.

The reaction of pupil diameter and skin conductance are widely studied marker of the autonomic response to arousing stimuli. However, little is known about their relation at rest. In this study, we used bivariate phase-rectified signal averaging to investigate the relationship of skin conductance fluctuations (SCF) and pupillary fluctuations in 83 healthy volunteers. The onset of each SCF was detected by a pattern matching algorithm. Those time points were corrected for a different neurotransmission delay. Cross-correlation of temporal derivatives of pupil diameter and skin conductance revealed an average time lag of 2.5s. Thus, anchor points 2.5s before an SCF were defined. The pupillary signal following these anchors (7s) were extracted and normalized to baseline 1s prior to the anchor point. Aligned segments were averaged to determine the amplitude and area under the curve (AUC) of characteristic pupil diameter fluctuations (PDF) concurrent to SCF. The same procedure was applied to random time points (non-SCF) with at least 1s distance to actually detected SCF which served as control condition. SCF were accompanied by increases of pupil diameter with a maximum dilation of 9% on average. The one sample t-test indicated an AUC of PDF (70 ± 110 n.u., p<; 0.001). The maximum change and AUC of pupillary reactions were significantly higher when PDF extraction was triggered by actual SCF (both p<; 0.001). Both measures of pupillary dilations contributed significantly to pupillary unrest. Our results suggest that sympathetic arousal as detected by skin conductance fluctuations is accompanied by pupil dilation.

VISUAL SCREENING OF SCHOOL CHILDREN IN THE MUNICIPALITY OF SAPAREVA BANYA IN SOUTHWESTERN BULGARIA

Within 3-days-program almost 200 children and 50 adults had their vision checked by an international qualified team of eye specialists in the local school in Sapareva Banya. Visual acuity, objective and subjective refraction, color perception, binocular vision, cover test, pupillary reaction and other tests were performed. Apart from the ophthalmic examination, all the patients’ parents also filled in questionnaire regarding visual strain regimen, previous eye doctor visits and other details. The aim was to promote visual health, establish and possibly treat refractive errors and amblyopia, to facilitate access to specialized medical care, optical and optometrist’s service for children’s population of remote municipalities with population under 10 000 people. The visual screening of Sapareva Banya school children was of great value because only 38% of children had been examined before. There were no major deviations, severe anisometropia and ametropia values or very low visual acuity patients not wearing optical correction. A surprisingly high incidence of color vision deficiency was found 9, 2% males and 4, 3 % females.

PB2313 OCULAR MANIFESTATIONS OF SICKLE CELL DISEASE: A SINGLE CENTRE STUDY

Background:Sickle cell disease (SCD) is an inherited haemolytic disorder that affects virtually all body systems including the eye. Ocular complications of SCD could have dire consequences if not detected early.Aims:We aimed at determining the prevalence of ocular complications of SCD in our patients.Methods:This study was carried out on patients attending both the adult and Paediatric Sickle cell clinic at Chukwuemeka Odumegwu Ojukwu teaching Hospital, Akwa, Anambra State, Nigeria, over a 6 month period. A structured questionnaire was administered to consenting patients to determine their sociodemographic variables and other characteristics. Visual acuity was determined with multiple optotype Snellen's chart at 6 metres in natural daylight. Using pen‐torch, the face, external eye examination, anterior segment examination and pupillary reaction to light were assessed. Magnified anterior segment examination was performed with slit‐lamp biomicroscope. All subjects underwent dilated fundoscopy (after instillation of tropicamide 0.5% eye drop) using Welch Allyn indirect ophthalmoscope.Results were analysed using SPSS version 22.0 Inc Chicago Illinois and represented in tables. Statistically significant P value was set at &lt; 0.05Results:A total of 28 patients with age range of 6‐42 years were seen. 17(60.7%) were males, while 11(39.3%) were females. 8(28.6%) had at least one ocular anomaly comprising of refractory errors 3(10.8%), sickle cell retinopathy 4(14.3%) and glaucoma 2(7.1%). Only 2(7.1%) routinely visit eye clinic. SCD retinopathy was found to increase with age (P value = 0.005)Summary/Conclusion:SCD retinopathy was found more in the older age group despite the small sample size at a prevalence rate of 14.3%. Early initiation of routine ocular examination for SCD patients will be beneficial to avert these complications. More efforts should be made at educating the patients. Larger studies will be required to determine the actual prevalence of ocular anomaly in SCD patients in Anambra State.

A comparison of manual pupil examination versus an automated pupillometer in a specialised neurosciences intensive care unit

BackgroundThe assessment of pupil size and reaction to light is a fundamental part of the neurological assessment; however, manual examination is prone to inaccuracies. The use of an automated infrared pupillometer is one strategy to limit error in pupil examination. ObjectiveThe main objective was to assess agreement between manual examination and examination using an automated infrared pupillometer in relation to pupil reaction and size in a specialised neurosciences intensive care unit. MethodsWe conducted a single-centre prospective observational study in a specialised tertiary neurosciences intensive care unit. Participants' pupils were examined hourly for 24 h by both manual examination using a pen torch and examination using an automated infrared pupillometer. ResultsTwenty-two participants were enrolled. A total of 935 paired pupil observations were obtained for both pupil reaction and size. There was no statistically significant disagreement in assessing pupil reaction (McNemar's test p = 0.106). Percentage agreement was 96.68% for pupil reaction, with Kappa coefficient, 0.841 (95% confidence interval: 0.7864–0.8956). For all participants, the mean difference in pupil size was 0.154 mm, with limits of agreement of −1.294 mm to +1.603 mm. ConclusionThere was no significant disagreement between manual and automated pupillometer observations for pupil reaction. The mean difference in measurement of pupil size was small.

Traumatic orbital third nerve palsy

We present a case series of three patients who developed acute traumatic orbital third nerve palsies. To our knowledge, reported cases have mainly been localised to the intracranial course of the nerve and often associated with visual impairment. Those in which the orbit is the site of injury are rare. Our case series highlights the importance of careful preoperative assessment of patients with orbital trauma (particularly when there is a coexisting fracture) and the need to assess ocular movements and pupillary reactions to distinguish between a neurogenic and soft tissue injury. Early diagnosis is helpful in deciding on the timing of the operation and enables patients to be given appropriate counselling to make sure that their expectations are realistic.

Neurological Pupil Index and Pupillary Light Reflex by Pupillometry Predict Outcome Early After Cardiac Arrest.

The absence of the pupillary light reflex (PLR) 3days after cardiac arrest predicts poor outcome, but quantitative PLR assessment with pupillometry early after recovery of spontaneous circulation (ROSC) and throughout targeted temperature management (TTM) has rarely been evaluated. Fifty-five adult patients treated with TTM with available pupillometry data from the NeurOptics NPi-200 were studied. Discharge outcome was classified good if the cerebral performance category score was 1-2, poor if 3-5. Pupil size, PLR percent constriction (%PLR), and constriction velocity (CV) were determined at TTM start and 6 (± 2)-h post-ROSC ("early"), and throughout TTM using data from the worst eye at each assessment. The Neurological Pupil index (NPi) was also determined at each pupil assessment; the NPi is scored from 0 (nonreactive) to 5 (brisk) with values < 3 considered sluggish or abnormal. Prognostic performance to predict poor outcome was assessed with receiver operator characteristic curves. All nine patients with ≥ 1 nonreactive pupil (NPi = 0) within 6 (± 2) h after ROSC died, and 12/14 (86%) with sluggish pupils (0 < NPi < 3) had poor outcomes. 15/29 (52%) patients with normal pupil reactivity (NPi ≥ 3) had poor outcomes, four survived with cerebral performance category = 3, three died of cardiac causes, and eight died of neurologic causes. During TTM, 20/21 (95%) patients with nonreactive pupils had poor outcomes, 9/14 (64%) of patients with sluggish pupils had poor outcomes, and 9/20 (45%) with normal pupil reactivity had poor outcomes. Pupil size did not predict outcome, but NPi (AUC = 0.72 [0.59-0.86], p < 0.001), %PLR (AUC = 0.75 [0.62-0.88], p < 0.001) and CV (AUC = 0.78 [0.66-0.91], p < 0.001) at 6h predicted poor outcome. When nonreactive pupils were first detected, 75% were < 5mm. Very early after resuscitation from cardiac arrest, abnormal Neurological Pupil index and pupillary light reflex measurements by pupillometer are predictive of poor outcome, and are not usually associated with dilated pupils.

Transcalvarial brain herniation volume as a predictor of posttraumatic hydrocephalus after decompressive craniectomy

ObjectivesIn patients undergoing decompressive craniectomy for traumatic brain injury(TBI) there has been reported an incidence of hydrocephalus between 0–45%. There are several radiological and clinical features described in association with development of hydrocephalus. For study the influence of these factors we conducted a retrospective observational single-center cohort study in a tertiary care center with special attention to the transcalvarial herniation(TCH) volume after decompressive craniectomy.Patients and methods: We selected 50 patients that underwent decompressive craniectomy after closed head injury between january 2014 and January 2015. Hydrocephalus was defined as a modified frontal horn index greater than 33%, presence of Gudeman CT scan criteria or insertion of ventriculoperitoneal Shunt. Variables analyzed were: age, post-resuscitation Glasgow coma scale (GCS) score, pupil reactivity, Zunkeller index, presence of hygroma, TCH volume, craniectomy diameter and distance of craniectomy from midline. Logistic regression was used with hydrocephalus as the primary outcome measure. Results17 patients developed hydrocephalus (34%). TCH volume after decompression(p < 0.01), subdural hygroma (p < 0.01), lower admission Glasgow Coma Scale score (p = 0.015), unilateral pupil reactivity(p = 0.042) and higher Zumkeller index(p = 0.044) were significant risk factors for hydrocephalus. Logistic regression analysis showed that factors independently associated with the development of hydrocephalus was the TCH volume (odds ratio 11.08; 95%CI 2.10, 58.4; p = 0.0046), and presence of hygroma (odds ratio 49.59; 95%IC 4.1, 459; p = 0.002). ConclusionsThere was a clear association between severity of TBI, TCH volume and subdural hygroma with the development of hydrocephalus. Clinicians should follow closely patients with those findings in order to avoid late deterioration.

Outcome of Craniocerebral Penetrating Injuries: Experience from the Syrian War.

Gunshot wounds to the brain are the most fatal of all firearm injuries. The aim of this study was to evaluate mortality and morbidity in patients with penetrating craniocerebral gunshot injuries and to identify risk factors that affect the outcome. A retrospective review from June 2012 to November 2013 of 44 Syrian patients with gunshot wound to the head was performed. A thorough physical examination and computed tomography (CT) of the brain was obtained for all patients at the time of admission. Associated systemic injuries were found in 19 patients (43%). Surgical intervention was performed in 25 patients (57%); the remaining patients were managed conservatively. The patients were followed for a period of 1 to 15 months (range: 6 ± 2 months). Univariate analysis of patient age, sex, type of penetrating object, Glasgow Coma Scale (GCS) score and pupil size on admission, brain CT findings, presence of systemic injuries, and surgical intervention on the patient outcome was performed. Eleven patients (25%) had a bullet injury; the remaining 33 (75%) patients had blast injuries. Initial brain CT revealed different types of skull fractures, intracerebral hemorrhage, and brain edema in all patients. The mortality rate during the follow-up period was 25%. Of the survivors, 25 patients (76%) had a good recovery, eight patients (24%) had a mild disability, and none had a severe disability. The significant factors determining outcome in this series were GCS on admission (p < 0.005) and positive pupil reaction to light (p < 0.05). The patient age, sex, CT findings, systemic injuries, neurosurgical intervention, and hospital length of stay were not significant prognostic factors (p > 0.05). Among various variables, GCS and pupil reactivity were the outcome predictors in patients with penetrating craniocerebral injuries. Age, sex, type of penetrating object, CT findings, and surgical intervention did not have a significant effect on survival for these kinds of injuries.

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

BackgroundElevated 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.MethodsThis 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).ResultsA 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 [T0 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).ConclusionsIn 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.

동공반응을 활용한 정서표현성 및 외향성의 예측

동공반응을 활용한 정서표현성 및 외향성의 예측

Dynamic assessment of the pupillary reflex in patients on high-dose opioids.

Background and aims Pupil size and reaction are influenced by opioids, an effect that is not considered to be affected by opioid tolerance. As clinicians have observed patients on high-dose opioids who exhibited seemingly normal pupil sizes, we wanted to dynamically assess the pupillary reflex in cancer patients on high-dose opioids. Methods We performed a dynamic assessment of the pupillary reflex in cancer patients on high-dose opioids and a control group of healthy volunteers using a portable, monocular, infrared pupillometer. We also performed a clinical examination and measured blood concentrations of opioids and their active metabolites. Results Sixty three patients who were on opioids for 2 months (median time) and on an oral morphine equivalent dose of 250 mg (median dose) were investigated. Most patients used more than one opioid. When correcting for age, pupil size in the group that had received no increase of opioid dose over the last 14 days was not significantly different from pupil size in the healthy volunteer group (p = 0.76), while the group that had increased the dose of opioids differed significantly from healthy volunteers (p = 0.006). We found no statistically significant correlation between total oral morphine equivalents and pupillary reactions or between blood opioid or opioid metabolite concentrations and baseline pupillary changes. Conclusion Pupillary changes do take place in patients on opioids. However, tolerance to these changes occurs when medication is not increased over time. Dynamic pupillometry can give additional information about the degree of tolerance to opioids. Implications These findings elucidate previous misconceptions regarding pupillary effects and tolerance to opioids.