Pupillary Reaction Research Articles

Age‐related changes in autonomic response: A pupillary light reflex and heart rate variability study

AbstractBackgroundAutonomic nervous system (ANS) dysfunction has been implicated with cardiovascular diseases, sudden‐cardiac‐death, and aging. The pupillary light reflex (PLR) and heart rate variability (HRV) are noninvasive tools of autonomic evaluation. However, the former remains underutilized in clinical practice.PurposeWe investigated the relationship between PLR, HRV, and aging to determine the normal distribution of age‐adjusted PLR and HRV measurements and to determine which method is best correlated with age.MethodsHealthy participants aged 18–65 years were recruited. Following a dark adaptation period, pupillary reactivity parameters were collected using an automated, commercial pupillometer. HRV measurements were derived using a high‐resolution electrocardiogram. Correlations of PLR and HRV parameters to age were computed using linear‐regression analysis.ResultsA total of 111 healthy participants were included. Older age was correlated with lower maximum and minimum pupillary diameters following dark adaptation and illumination (R = −0.51, p < 0.001 and R = −0.47, p < 0.001, respectively). Average constriction and dilatation velocity were correlated with age (R = 0.33, p < 0.001 and R = −0.21, p = 0.025, respectively). HRV parameters were also associated inversely with age (SDNN; R = −0.31, p < 0.001 and RMSSD; R = −0.33, p < 0.001). Other parameters showed lower significance levels.ConclusionPupillary light reflex measurements demonstrated stronger age correlation than short‐term HRV time‐domain indices. Due to its merit in depicting normal age‐related ANS changes, PLR can be utilized to differentiate between pathological and physiological deviations from age‐adjusted norms, seemingly better than HRV. Further research is warranted on incorporating PLR‐based ANS dysfunction evaluation and monitoring the increasingly aging population.

Role of Decompressive Craniectomy/ Hemicraniectomy in the Management of Traumatic Brain Injury: A Retrospective Study

Introduction: Head injury is one of the most common outcomes of any kind of trauma becoming the major cause of morbidity and mortality worldwide. The critical element in the treatment of patients with severe head injuries is to prevent the progression of the condition and secondary insult to brain cells. Various protocols are followed for the treatment of severe head injury starting from conservative medical management to surgical approaches like DC/hemicraniectomy (DC). The DC is a surgical method of removal of part of skull bone so that the brain parenchyma gets space to expand and the Intracranial Pressure (ICP) can get reduced. There are various factors that contribute to the outcome of DC. Aim: To determine the various factors that affect the outcome of DC/hemicraniectomy. Materials and Methods: A retrospective descriptive study was conducted in the Institute of Gandhi Medical College and associated Hamidia hospital, Madhya Pradesh, India from May 2017 to April 2021. Hundred patients with moderate to severe head injury who underwent primary DC were included in this study. The variables such as age, preoperative GCS, the timing of surgery, preoperative pupillary reaction, and MidLine Shift (MLS) were compared in terms of survival/death and favourable/ unfavourable outcomes using the chi-square test. Results: The mean age of participants was 45±14 years. Statistical analysis showed significant results for the variables like age, preoperative the Glasgow Coma Scale (GCS), timing of the surgery, pupillary reaction at presentation, and preoperative MLS in terms of survival/death and favourable/ unfavourable outcomes. Conclusion: Younger age group, better preoperative GCS, early surgery, reactive pupils at presentation, and less preoperative MLS have positive outcome benefits with the DC/ hemicraniectomy to reduce the raised ICP.

The Role of Nursing Care in the Management of Patients with Traumatic Subarachnoid Hemorrhage.

Traumatic subarachnoid hemorrhage (tSAH) is a critical condition that requires comprehensive management to optimize patient outcomes. Nursing care plays a key role in the overall management of patients with tSAH via various aspects of care, including neurological assessment, monitoring, intervention, and education. In this review, we aim to evaluate the significant contributions of nursing care in managing patients with tSAH. Nurses perform initial neurological assessments, including the glasgow coma scale, pupil reactivity, vital signs, and sensory-motor evaluations. These assessments provide valuable information for early identification of deteriorating neurological status and prompt intervention. Additionally, nurses closely monitor intracranial pressure (ICP), cerebral perfusion pressure, and other hemodynamic parameters, assisting in the prevention and timely detection of secondary brain injury. For example, some strategies to manage ICP include elevating the head of the bed, maintaining adequate oxygenation and ventilation, administering proper medications, and ensuring fluid and electrolyte balance. Also, through careful monitoring, early recognition, and appropriate preventive measures, nursing care could prevent complications, including infections, deep vein thrombosis, and pressure ulcers. Furthermore, nursing care extends beyond physical management and encompasses psychosocial support for patients and their families. Nurses establish therapeutic relationships, providing emotional support, education, and counseling to alleviate anxiety, address concerns, and facilitate coping mechanisms. Education regarding medication management, lifestyle modifications, and the importance of regular follow-up enhances patient compliance and promotes long-term recovery.

Direct vs. Indirect Etiology of Traumatic Optic Neuropathy

When it comes to vision, there is a rare condition which has more potential to impair the vision, and this condition is called Traumatic optic neuropathy. Direct traumatic optic neuropathy occurs when there is direct physical trauma to the optic nerve, often due to penetrating injuries or fractures involving the bones around it. On the other hand, indirect (TON) is caused by blunt force trauma that is transmitted through the tissues or bones around the eye, leading to stretching, tearing, or damage to the blood supply of the optic nerve. Common causes of indirect (TON) include motor vehicle accidents, falls, assaults, and sports-related injuries. The mechanics, blood flow, and inflammation are all sequentially organized in Traumatic optic neuropathy. Mechanical factors disrupt the integrity of the nerve fibers and blood supply, vascular factors reduce the blood flow, and inflammatory factors activate processes that cause cell death within the optic nerve. The signs of (TON) can vary in presentation. Commonly involve a decrease in visual clarity abnormalities in the pupil's reaction to light visual field issues, changes in color perception, and alterations in the appearance of the optic disc. Diagnosing and managing (TON) can be quite challenging since there are no markers or reliable predictors of prognosis. In some cases, observation may be appropriate, while corticosteroids can be employed for their inflammatory properties and potential benefits to optic nerve blood supply. Surgical decompression focuses on relieving pressure or removing obstructions that are affecting the nerve.

Cerebral venous sinus thrombosis- a potential complication of chickenpox: Case Report

Chickenpox(varicella) is mostly a self-limiting disease of childhood. Chickenpox-related neurological complications can occur in less than 1% of cases, of which cerebral venous sinus thrombosis is a very rare complication that may be due to primary infection, post viral hypercoagulable state or reactivation of the virus. Case presentation We reported a case of a 25-year-old male adult patient who presented with complaints of diplopia, photophobia, vomiting, and headache 10 days after the onset of chickenpox rashes. He had healed lesions with scabs over the trunk and extremities. Discussion Neurological examination was normal except for abnormal pupillary reaction and decreased visual acuity. Fundoscopy revealed papilloedema. Blood and metabolic parameters were normal. Magnetic resonance imaging showed signs suggestive of superior sagittal sinus thrombosis. MR Venography was denied by the patient due to personal reason. Inj. LMWH and Mannitol were given for 5 days followed by dabigatran. The patient reported improvement in vision and other symptoms after treatment. Conclusion- The possible link between chickenpox and cerebral venous sinus thrombosis is still not clear but some literature showed it might be due to endothelial damage by viruses and a few cases reported in the pediatric population. Some case-control studies should be targeted to find out possible associations.

Successful Management of an Acute Case of Orbital Cellulitis of Odontogenic Origin.

Sir, Dental infections left untreated can progress through tissue planes into the orbital space through sinuses and result in orbital abscess which is an ophthalmic emergency. We describe the case of a 47-year-old female, a known diabetic who presented with complaints of severe swelling and pain in periorbital region, associated with fever, vomiting, and prostration for 20 days’ duration. She gave a history of repeated episodes of dental pain arising out of her impacted upper third molar tooth for the past 2 months. Ocular examination of the right eye showed significant proptosis of 24 mm, restriction of extraocular movements in all directions, normal pupillary reaction with best-corrected visual acuity of 6/24, and intraocular pressure of 21 mm of Hg [Figure 1a]. Magnetic resonance imaging (MRI) showed heterogeneous multifocal lesions in the right orbit with T1 hypointensity, T2 hyperintensities with internal septation in the intra-conal and extraconal compartments producing compression over the globe [Figure 1b]. Dental X-ray was suggestive of impacted right maxillary third molar tooth [Figure 1c]. On the second day of her hospital stay, she developed multiple upper and lower eyelid pre-septal and post-septal abscesses which were drained, and the pus was sent for culture and sensitivity. Systemic antibiotics were started in the form of intravenous piperacillin/tazobactam (4.0/0.5 g) 8 hourly, metronidazole (500 mg/100 ml) 8 hourly, and oral linezolid (600 mg) 12 hourly. Blood sugars were monitored and insulin was administered as per her requirement. She was referred to dental surgeon for extraction of the impacted molar tooth. She recovered completely with best-corrected visual acuity of 6/9 and intraocular pressure of 16 mm of Hg. She showed remarkable improvement at 2 weeks after tooth extraction [Figure 1d].Figure 1: (a) Clinical photograph at presentation showing severe proptosis, complete ptosis, erythema, restricted extraocular movements, and pus pointing over lower eyelid skin. (b) MRI sagittal section T1 image showing multiloculated abscesses in intraconal and extraconal compartment of right orbit causing compression of eyeball. (c) Right maxillary posterior intraoral periapical radiograph showing impacted upper third molar tooth. (d) Clinical photograph of the same patient after two weeks with complete resolution of edema, proptosis, and extraocular movements. MRI: Magnetic resonance imagingOrbital cellulitis secondary to dental infection is rare accounting for 2%-5% of all cases of orbital infections.[1] To add to its rarity, orbital abscess constitutes less than 1.3% of abscesses seen in maxillofacial region.[2] Surgical drainage of the abscess and pus sample collection is a recommended modality of treatment as reported by many authors.[3,4] Empirical antibiotics and proper intravenous fluid hydration are mainstay of treatment. Systemic corticosteroids fasten the resolution of inflammation and duration of hospital stay.[5] A multidisciplinary approach with dentists, diabetologists, and ophthalmologists is required to prevent serious complications of venous sinus thrombosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Research quality and ethics statement The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Comparision between the Glasgow Coma Scale and Glasgow Coma Scale Pupil reactivity score in predicting mortality in traumatic brain injury patients

Introduction: Glasgow Coma Scale (GCS) and the pupillary response are the key indicators of the severity of traumatic brain injury (TBI). Glasgow coma scale- Pupil reactivity (GCS-P) score is a tool to incorporate pupil reactivity and GCS into a simple single index. The main aim of this study was to compare GCS and GCS- P scores in predicting mortality in TBI patients in our institution. Materials and Methods: All patients admitted to Tribhuvan University Teaching Hospital (TUTH) with moderate to severe head injury from May 2018 to April 2019 were included in the study. Both GCS and GCS- P scores were recorded separately at admission. Outcome was measured with Glasgow Outcome Scale (GOS) at the time of discharge and in three months. Diagnostic accuracy of both these scoring systems were calculated using receiver-operating characteristics (ROC) curve, and correlation between them was estimated by using Pearson correlation coefficient. Results: Out of 136 patients enrolled, 98 patients had favorable outcome, 38 patients had unfavorable outcome at discharge. The Pearson correlation coefficient between GCS and GOS at discharge was 0.721 and GCS-P and GOS was 0.740 showing a good correlation between the GCS and GOS and GCS-P and GOS. The areas under ROC curve for GCS for prediction of mortality was 0.856 (95% CI; p<0.001) and for GCS-P is 0.871(95%CI;p<0.001) suggesting good discriminatory ability of both models. However, on statistical analysis, the discriminatory ability of GCS-P was not superior to GCS for mortality. Conclusion: GCS-P is as good as but not superior to GCS in predicting mortality in traumatic brain injury patients.

Erythropoietin as a treatment option for indirect traumatic optic neuropathy: A pilot study.

Our study aims to evaluate the effectiveness of intravenous erythropoietin (EPO) in patients with indirect traumatic optic neuropathy (TON), assess the side effects, and compare the visual function results among three groups of patients who had received different treatment options - EPO, steroids, and observation. : Patients with indirect TON presenting to the neuro-ophthalmology clinic from August 2019 to March 2020, were assigned to three groups, with six patients in each group. In group 1, patients were recruited prospectively and received recombinant human erythropoietin, whereas, in groups 2 and 3, patients were recruited retrospectively and received intravenous methylprednisolone followed by oral steroids and multivitamins, respectively. Groups 1 and 2 included patients presenting within 2 weeks of trauma, whereas group 3 included those presenting beyond that. Best-corrected visual acuity, pupillary reaction, color vision, and visual fields following treatment were measured. Initial visual acuity in the EPO group ranged from 20/80 to no perception of light (No PL). The mean initial BCVA (1.82 logMAR, standard deviation [SD] = 0.847) improved to 1.32, SD = 0.93 logMAR after treatment recorded at the third month (P = 0.0375), with no significant adverse effects. The initial BCVA of group 2 ranged from 20/120 to No PL. The mean initial BCVA (1.95, SD = 0.77 logMAR) improved to 1.45 logMAR, SD = 0.97 after treatment (P = 0.0435) but three patients had side effects of steroids. Initial visual acuity in Group 3 ranged from 20/40 to no PL. The mean initial BCVA (1.09 logMAR, SD = 1.10) worsened to 1.19 logMAR, SD = 1.06 after treatment after treatment (P = 0.0193). The improvement in BCVA when compared between the three groups was not significant. Both erythropoietin and steroids are effective in the management of traumatic optic neuropathy. However, erythropoietin shows lesser or no side effects when compared to steroids.

ICT Technologies in the Education of Elementary School Pupils in the Czech Republic

The paper deals with the state of implementation and usage of Information and Communication Technologies (ICT) in the education of elementary school pupils in the Czech Republic. The aim of the research is to find out the opinions of teachers on the use of ICT in teaching and the extent to which these teachers use ICT technology in teaching, how, for what purpose and how, the use of ICT technologies is related to subjects and other relevant variables in the school context. The questionnaire survey was conducted among 103 primary school teachers in several primary schools. Respondents were selected on the basis of their willingness and voluntariness to participate anonymously in the research survey. The results of the research showed that the competencies of primary school teachers using ICT in teaching were relatively developed. We found that teachers use ICT not only in the teaching process, but also for communication with students, colleagues and parents. Our assumption was confirmed that ICT technologies were used significantly more in science than in humanities (except language subjects). According to teachers, the reaction of pupils to the use of ICT in teaching was positive.

Correlation of symptoms registered during blood collection from drivers who tested positive for Δ9-tetrahydrocannabinol (THC)

The impact of marijuana on road safety has been the subject of many debates over the years. These debates have intensified in recent years due to initiatives carried out in several jurisdictions aimed at marketing medical cannabis. According to Polish forensic toxicologists, road safety is a key issue, especially following the conferences in November 2012 in Kraków and in 2013 in Augustów (Gieroń et al., 2013), Poland, on the determination of appropriate concentration thresholds. These thresholds, defining the limit for the ‘after use’ and ‘under the influence’ conditions, are still not unambiguous or easy to determine for the Polish government. An unambiguous assessment of the impact of a given concentration of blood Thc on psychomotor performance is very difficult, and will remain so in the foreseeable future. This study used 107 randomly selected blood collection protocols, with 10 protocols for each THC concentration ranging from 1 to 10 ng/ml, on the basis of which thirteen features related to the external appearance and behaviour of the tested individuals were analysed. These features were: facial skin (pale, normal or red), slurred speech, mood and behaviour (cheerful, talkative, rowdy or reticent), heart rate, pupils (normal, dilated or contracted), reaction of pupils to light, the romberg test, the finger-to-nose test, picking up objects from the ground and awareness of time and place. Five of the thirteen features related to the appearance and behaviour of the respondents showed no abnormalities (gait, the romberg test, the finger-to-nose test, picking up objects from the ground, and awareness of time and place). The study found that the symptoms observed and recorded in the protocols are insufficient to make a decision about the impact of Thc on psychomotor performance. The characteristic symptoms (cheerfulness and talkativeness) occurred no more frequently than in 3 out of 10 of the concentrations tested.

Quantitative assessments of pupillary light reflexes in neurocritically ill patients

The pupillary light reflex (PLR) is a component of bedside neurological examinations in neurological intensive care units (neuroICUs). A quantitative pupillometer provides a non-invasive and objective pupil reactivity parameter clinically significant for changes in PLR in neuroICUs. This article reviews the physiology and importance of the PLR and the parameters of quantitative pupillometers. Moreover, this review discusses the clinical applications of quantitative pupillometers for post-cardiac arrest prognostication and monitoring of elevated intracranial pressure and neurological worsening in stroke, seizures, and other neurological diseases in the neuroICU. Quantitative pupillometry is a routine part of neurological examinations and an important monitoring tool for neurological diseases in neuroICUs.

A study of posterior reversible encephalopathy syndrome as a cause of sudden transient vision loss during pregnancy

To emphasize the importance of Posterior Reversible Encephalopathy syndrome (PRES) as the cause of sudden vision loss during pregnancy in patients with acute haemodynamic instability like preeclampsia, eclampsia, severe PIH.: In this prospective observational study pregnant women within age group of 25-40 years presenting with acute onset of visual, neurological symptoms to the emergency department were examined. Blood pressure recorded. Patients vision was recorded using snellens chart at the time of presentation and after the recovery. Slit lamp examination, fundus examination, pupillary reactions were noted to rule out other causes of vision impairment. MRI was done to detect PRES. Patients were stabilised and their blood pressure was monitored and treated with intravenous anti hypertensives.: 8 out of 10(80%) of the pregnant women presented with sudden vision impairment were preeclamptic and 2 out of 10(20%) were with features of eclampsia. Majority were in third trimester. All the patients were diagnosed early with PRES on MRI and regained vision within 2 days with immediate treatment with intravenous antihypertensives.Posterior Reversible Encephalopathy syndrome has to be kept in mind as one of the differential diagnosis while examining the pregnant women with eclampsia, preeclampsia, PIH coming with sudden visual impairment.

Clinical Profile of Patients with Bilateral Optic Disc Swelling Attending in an Apex Eye Hospital in Bangladesh

Background: Patient with optic disc swelling demands thorough ophthalmic as well as systemic evaluation as it may reflect intraocular as well as systemic diseases. Early diagnosis and proper management of bilateral disc swelling is important, as it can save vision as well as life. This study is aimed to determine the socio-demographic and clinical profile of patients with bilateral optic disc swelling in a tertiary eye hospital of Bangladesh.
 Methods: This cross sectional study had been conducted over 102 patients with bilateral disc swelling at the Neuroophthalmology clinic of National institute of ophthalmology and Hospital, Dhaka between April 2019 and March 2020. Patients were selected purposively based on specific selection criteria. Detail history was taken, ocular examinations like visual acuity, color vision, field of vision, pupillary light reaction, fundus examination were done and relevant investigations included color fundus photograph, visual field analysis, Computed tomography scans and Magnetic Resonance Imaging were performed. All the information’s were recorded in a pre-designed data collection sheet.
 Results: The mean age of the patients was 30.2±10.8 years where 37.3% patients were from 18-27 year age group. Females (67.7%) were commonly presented with bilateral disc swelling than male (33.3%). Most of the patients commonly presented with the symptoms like headache (71.6%), dimness of vision (62.8%), nausea & vomiting (42.2%), ocular pain (21.6%) etc. Best corrected visual acuity of the study population was within 0-0.3 log MAR unit in the right eye in 55.9% cases and in the left eye in 59.8% cases. Majority of the patients (Right eye: 60.8%, Left eye: 63.7%) could read all plates while color vision assessment. About 20% patient had RAPD. About 17% patients had field defect in their right eyes whereas about 15% had visual filed defect in left eyes. Other than disc swelling, 14 patients had diplopia (13.7%), 12 patients had uveitis (11.8%). Out of 102 patients, 36 patients were clinically diagnosed as IIH (35.3%). Others were diagnosed as ICSOL (24.5%), bilateral optic neuritis (12.7%), VKH (12.7%), grade-IV hypertensive retinopathy (8.8%). The analysis of neuro imaging findings among the patients showed 72 patients (70.6%) had no space occupying lesions, 9 patients (8.8%) had meningioma, 6 patients had CP angle tumor (5.9%), 5 patients had empty sella (4.9%).
 Conclusions: Most of the Bangladeshi patients with bilateral disc swelling report to neuro-ophthalmology clinic in NIO&H are female and belong to 18-37 years age group. Among them headache is the most common presenting complaint and IIH is the most common clinical diagnosis.
 J. Natl. Inst. Ophthalmol. 2022;5(1):39-45

Quantitative pupillometry and radiographic markers of intracranial midline shift: A pilot study.

Asymmetric pupil reactivity or size can be early clinical indicators of midbrain compression due to supratentorial ischemic stroke or primary intraparenchymal hemorrhage (IPH). Radiographic midline shift is associated with worse functional outcomes and life-saving interventions. Better understanding of quantitative pupil characteristics would be a non-invasive, safe, and cost-effective way to improve identification of life-threatening mass effect and resource utilization of emergent radiographic imaging. We aimed to better characterize the association between midline shift at various anatomic levels and quantitative pupil characteristics. We conducted a multicenter retrospective study of brain CT images within 75 min of a quantitative pupil observation from patients admitted to Neuro-ICUs between 2016 and 2020 with large (>1/3 of the middle cerebral artery territory) acute supratentorial ischemic stroke or primary IPH > 30 mm3. For each image, we measured midline shift at the septum pellucidum (MLS-SP), pineal gland shift (PGS), the ratio of the ipsilateral to contralateral midbrain width (IMW/CMW), and other exploratory markers of radiographic shift/compression. Pupil reactivity was measured using an automated infrared pupillometer (NeurOptics®, Inc.), specifically the proprietary algorithm for Neurological Pupil Index® (NPi). We used rank-normalization and linear mixed-effects models, stratified by diagnosis and hemorrhagic conversion, to test associations of radiographic markers of shift and asymmetric pupil reactivity (Diff NPi), adjusting for age, lesion volume, Glasgow Coma Scale, and osmotic medications. Of 53 patients with 74 CT images, 26 (49.1%) were female, and median age was 67 years. MLS-SP and PGS were greater in patients with IPH, compared to patients with ischemic stroke (6.2 v. 4.0 mm, 5.6 v. 3.4 mm, respectively). We found no significant associations between pupil reactivity and the radiographic markers of shift when adjusting for confounders. However, we found potentially relevant relationships between MLS-SP and Diff NPi in our IPH cohort (β = 0.11, SE 0.04, P = 0.01), and PGS and Diff NPi in the ischemic stroke cohort (β = 0.16, SE 0.09, P = 0.07). We found the relationship between midline shift and asymmetric pupil reactivity may differ between IPH and ischemic stroke. Our study may serve as necessary preliminary data to guide further prospective investigation into how clinical manifestations of radiographic midline shift differ by diagnosis and proximity to the midbrain.

Man with betel nut toxicity

A 36-year-old Burmese male was found unresponsive at his place of work with possible seizure-like activity. The patient received naloxone by Emergency Medical Services with no response. Upon ED arrival, the patient was tachycardic, hypertensive, with a Glasgow Coma Score of 3, and sluggishly reactive but equal pupils of 4 mm

An independent, external validation and component analysis of the Surviving Penetrating Injury to the Brain score for civilian cranial gunshot injuries.

The Surviving Penetrating Injury to the Brain (SPIN) score utilizes clinical variables to estimate in-hospital and 6-month mortality for patients with civilian cranial gunshot wounds (cGSWs) and demonstrated good discrimination (area under the receiver operating characteristic curve [AUC] 0.880) in an initial validation study. The goal of this study was to provide an external, independent validation of the SPIN score for in-hospital and 6-month mortality. To accomplish this, the authors retrospectively reviewed 6 years of data from their institutional trauma registry. Variables used to determine SPIN score were collected, including sex, transfer status, injury motive, pupillary reactivity, motor component of the Glasgow Coma Scale (mGCS), Injury Severity Score (ISS), and international normalized ratio (INR) at admission. Multivariable logistic regression analysis identified variables associated with mortality. The authors compared AUC between models by using a nonparametric test for equality. Of the 108 patients who met the inclusion criteria, 101 had all SPIN score components available. The SPIN model had an AUC of 0.962. The AUC for continuous mGCS score alone (0.932) did not differ significantly from the AUC for the full SPIN model (p = 0.26). The AUC for continuous mGCS score (0.932) was significantly higher compared to categorical mGCS score (0.891, p = 0.005). Use of only mGCS score resulted in fewer exclusions due to missing data. No additional variable included in the predictive model alongside continuous mGCS score was a significant predictor of inpatient mortality, 6-month mortality, or increased model discrimination. Given these findings, continuous 6-point mGCS score may be sufficient as a generalizable predictor of inpatient and 6-month mortality in patients with cGSW, demonstrating excellent discrimination and reduced bias due to missing data.

Orbital Fractures and Risk Factors for Ocular Injury.

To identify factors predictive of serious ocular injury requiring urgent consultation by ophthalmology in patients presenting with blunt trauma orbital fractures. This is a retrospective study of adult patients diagnosed with orbital fractures after blunt trauma at a university medical center emergency room. Patient records were examined over a three-year period. Data including mechanism of injury, fracture location, ocular symptoms, and examination findings were recorded. Ocular injuries were divided into three levels of severity: mild, moderate, and severe. Fracture characteristics, patient demographics, and examination findings were analyzed using multinomial regression to identify risk factors for more severe injury. One hundred and eighty-six patients met inclusion criteria. For 29.6% of patients, urgent ophthalmologic consultation was required. Ruptured globes occurred in 2.2% of injuries. There was a statistically significant association between severe ocular injury and three examination findings: poor vision (OR 14.5; p < 0.001), afferent pupillary defect (OR 44.8; p < 0.001), and abnormal pupillary reaction (OR 28.0; p < 0.001). Likewise, blurry vision (OR 3.6; p = 0.018), ocular pain (OR 3.7; p = 0.011), and facial pain (OR 4.4; p = 0.031) were also associated with an increased risk of severe ocular injury. Abnormal pupillary reaction was associated with moderate injury (OR 4.5; p = 0.041). Demographic factors, mechanism of injury, anti-coagulant use, fracture location, diplopia, no documented vision, subconjunctival hemorrhage, chemosis, and motility restriction were not associated with injury severity. Most patients who presented to the emergency room with an orbital fracture did not require urgent ophthalmologic consultation. The presence of blurry vision, ocular pain, facial pain, poor vision, and afferent pupillary defect significantly increased the odds of severe injury. Abnormal pupillary reaction was associated with both moderate and severe injury.

Facial mask disturbs ocular exploration but not pupil reactivity.

The COVID-19 pandemic has imposed to wear a face mask that may have negative consequences for social interactions despite its health benefits. A lot of recent studies focused on emotion recognition of masked faces, as the mouth is, with the eyes, essential to convey emotional content. However, none have studied neurobehavioral and neurophysiological markers of masked faces perception, such as ocular exploration and pupil reactivity. The purpose of this eye tracking study was to quantify how wearing a facial accessory, and in particular a face mask, affected the ocular and pupillary response to a face, emotional or not. We used videos of actors wearing a facial accessory to characterize the visual exploration and pupillary response in several occlusion (no accessory, sunglasses, scarf, and mask) and emotional conditions (neutral, happy, and sad) in a population of 44 adults. We showed that ocular exploration differed for face covered with an accessory, and in particular a mask, compared to the classical visual scanning pattern of a non-covered face. The covered areas of the face were less explored. Pupil reactivity seemed only slightly affected by the mask, while its sensitivity to emotions was observed even in the presence of a facial accessory. These results suggest a mixed impact of the mask on attentional capture and physiological adjustment, which does not seem to be reconcilable with its strong effect on behavioral emotional recognition previously described.

Predictive Factors of Outcomes in Acute Subdural Hematoma Evacuation.

This comparative cross-sectional study was conducted in the Departments of Trauma and Neurosurgery, Ayub Teaching Hospital,Abbottabad, Pakistanfrom September 2021 to February 2022to study predictive factors of outcomes in acute subdural hematoma evacuation. A total of 101 patients with confirmed diagnosis of acute subdural hematoma (ASDH) who underwent surgical evacuation by consultant neurosurgeon were included in the study. A detailed clinical proforma was designed to document all the clinical and demographic details of these patients at the time of admission. Glasgow Coma Scale outcome score (GOS)was used to assess the outcome of patients after the surgery. Sociodemographic and clinical parameters were associated withoutcome of surgery in our study participants. Out of 101 patients, 55 (54.5%) were males and 46 (45.5%) were females. Mean age was 43.66±19.66 years with 7.39 as mean Glasgow Coma Scale (GCS) at presentation. Road traffic accident (RTA) 62 (61.4%) was most frequent mechanism of injury followed by fall from height (19.8%) and history of assault (13.9%). In our study, 59 patients had poor outcomes while 42 had good outcomes. Elder age, low GCS at presentation, and use of oral anticoagulant were associated with poor outcomes while pupillary reaction had no effect on the outcome after application of test of significance. More than half of the patients managed with surgical evacuation for acute subdural hematoma as per guidelines at our neurosurgical unit had poor outcomes according toGlasgow Coma Scale. In this study, advancing age (>60 years), low GCS score at presentation, and use of oral anticoagulation therapy emerged as significant risk factors for poor outcomes in participants. Pupillary reaction had no effect on outcomes as per this study but this needsfurther evaluation in future studies.

Vertex epidural hematoma: Diagnosis, therapeutic consideration and outcome

ObjectiveVertex epidural hematoma (VEDH) is a relatively uncommon type of intracranial hematoma. Because of its unique location and the potential of massive intraoperative bleeding, diagnosis and surgical intervention of VEDH may be challenging. Materials and methodsA retrospective analysis of 32 patients with VEDH was undertaken to investigate the prognostic factor and therapeutic strategy of VEDH. Special attention was paid to the relationship between fracture pattern, surgical method, intraoperative blood loss and outcome. ResultsPatients treated surgically had a higher percentage of consciousness disturbance and a significantly larger size of VEDH compared with patients treated conservatively (p = 0.029 and p < 0.0001, respectively). Bleeding from the injured superior sagittal sinus (SSS) was noted in six of nine patients (67%) with a linear fracture parallel to the SSS. Only one patient (20%) with a linear fracture crossing the SSS had bleeding from the injured SSS. Five of eight patients (63%) with sagittal suture diastasis experienced bleeding from the SSS. All patients with massive blood loss and six of seven patients developing intraoperative shock had copious bleeding from the injured SSS. All patients with intraoperative massive bleeding and shock underwent traditional “simple craniotomy”. No patients undergoing “strip craniotomy” experienced massive bleeding. Thrombocytopenia (p = 0.008), headache (p = 0.015), consciousness disturbance (p = 0.043), pupil reactivity (p = 0.010), GCS score (p < 0.0001) and the relationship between skull fracture and the SSS (p = 0.037) were significant prognostic factors. ConclusionOur study demonstrated GCS score may be a significant prognostic factor in patients with VEDH. Bleeding from the injured SSS occurred frequently in VEDH patients with a linear skull fracture parallel to the SSS or sagittal suture diastasis and could cause devastating hemorrhage. When operating on such patients, the surgical team should prepare for the possibility of massive blood loss and intraoperative shock. Bilateral parasagittal craniotomies with preservation of a central bone strip containing the sagittal suture (strip craniotomy) to allow application of tack-up sutures from the dura to the bone strip may be more suitable for VEDH evacuation.