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Current Neurology and Neuroscience Reports

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01-10-2019 | Central Nervous System Trauma | Critical Care (Stephan A. Mayer, Section Editor)

Automated Pupillometry in Neurocritical Care: Research and Practice

Authors: Bethany L. Lussier, DaiWai M. Olson, Venkatesh Aiyagari

Published in: Current Neurology and Neuroscience Reports | Issue 10/2019

Abstract

Purpose of Review

The purpose of this review is to examine the impact of pupillometer assessment on care and research of patients with neurological injury.

Recent Findings

Recent studies demonstrate that automated pupillometry outperforms manual penlight pupil examination in neurocritical care populations. Further research has identified specific changes in the pupillary light reflex associated with pathologic conditions, and pupillometry has been used to successfully identify early changes in neurologic function, intracranial pressure, treatment response to osmotherapy, and prognosis after cardiac arrest.

Summary

Automated pupillometry is being increasingly adopted as a routine part of the neurologic examination, supported by a growing body of literature demonstrating its reliability, accuracy, and ease of use. Automated pupillometry allows rapid, non-invasive, reliable, and quantifiable assessment of pupillary function which may allow rapid diagnosis of intracranial pathology that affects clinical decision making.

Emelifeonwu JA, Reid K, Rhodes JK, Myles L. Saved by the pupillometer! - a role for pupillometry in the acute assessment of patients with traumatic brain injuries? Brain Inj. 2018;32(5):675–7.PubMed

• Olson DM, Stutzman S, Saju C, Wilson M, Zhao W, Aiyagari V. Interrater reliability of pupillary assessments. Neurocrit Care. 2016;24(2):251–7 Established reliability and evidence for standardization of assessment, highlighted low reliability of manual pupillary examination in current standard practice. PubMed

Couret D, Boumaza D, Grisotto C, Triglia T, Pellegrini L, Ocquidant P, et al. Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study. Crit Care (London, England). 2016;20:99.

Kerr RG, Bacon AM, Baker LL, Gehrke JS, Hahn KD, Lillegraven CL, et al. Underestimation of pupil size by critical care and neurosurgical nurses. American journal of critical care : an official publication, American Association of Critical-Care Nurses. 2016;25(3):213–9.

Meeker M, Du R, Bacchetti P, Privitera CM, Larson MD, Holland MC, et al. Pupil examination: validity and clinical utility of an automated pupillometer. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses. 2005;37(1):34–40.

Ortega-Perez S, Amaya-Rey MC. Secondary brain injury: a concept analysis. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses. 2018;50(4):220–4.

Klein SP, Depreitere B. What determines outcome in patients that suffer raised intracranial pressure after traumatic brain injury? Acta Neurochir Suppl. 2018;126:51–4.PubMed

• Ortega-Perez S, Shoyombo I, Aiyagari V, Atem F, Hill M, Stutzman SE, et al. Pupillary light reflex variability as a predictor of clinical outcomes in subarachnoid hemorrhage. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses. 2019;51(4):171–5 Novel use of pupillometry to predict clinical outcome in aneurysmal subarachnoid hemorrhage.

Riker RR, Sawyer ME, Fischman VG, May T, Lord C, Eldridge A, et al. Neurological pupil index and pupillary light reflex by pupillometry predict outcome early after cardiac arrest. Neurocrit Care. 2019.

10.

Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81–4.PubMed

11.

• Shoyombo I, Aiyagari V, Stutzman SE, Atem F, Hill M, Figueroa SA, et al. Understanding the relationship between the neurologic pupil index and constriction velocity values. Sci Rep. 2018;8(1):6992 Defined relationship between NPi and constriction velocity and emphasized that having a brisk constriction velocity does not rule out an abnormal pupillary light reflex. PubMedPubMedCentral

12.

Zhao W, Stutzman S, Olson D, Saju C, Wilson M, Aiyagari V. Inter-device reliability of the NPi-100 pupillometer. J Clin Neurosc. 2016:ePub.

13.

• Jahns FP, Miroz JP, Messerer M, Daniel RT, Taccone FS, Eckert P, et al. Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury. Crit Care (London, England). 2019;23(1):155 First study to correlate quantitative pupillometry measures to changes in intracranial pressure in traumatic brain injury.

14.

• Aoun SG, Stutzman S, Vo P-UN, Ahmadieh TYE, Osman M, Neeley O, et al. Detection of delayed cerebral ischemia using objective pupillometry in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg. 2019;1 First study, though small sample size, to demonstrate correlation and possible predictive value of abnormal pupillometry measurements in development of delayed cerebral ischemia.

15.

Osman M, Stutzman S. Folefac A. J Stroke Cerebrovasc Dis: Correlation of objective pupillometry to midline shift in acute stroke patients; 2019.

16.

• Natzeder S, Mack DJ, Maissen G, Strassle C, Keller E, Muroi C. Portable infrared pupillometer in patients with subarachnoid hemorrhage: prognostic value and circadian rhythm of the Neurological Pupil Index (NPi). J Neurosurg Anesthesiol. 2018; First study, though small sample size, to correlate pupillometry findings with clinical severity of aneurysmal subarachnoid hemorrhage.

17.

• Ong C, Hutch M, Barra M, Kim A, Zafar S, Smirnakis S. Effects of osmotic therapy on pupil reactivity: quantification using pupillometry in critically ill neurologic patients. Neurocrit Care. 2019;30(2):307–15 Novel use of quantitative pupillometry to monitor treatment effect of osmotic therapy for intracranial hypertension. PubMed

18.

Wildemeersch D, Baeten M, Peeters N, Saldien V, Vercauteren M, Hans G. Pupillary dilation reflex and pupillary pain index evaluation during general anaesthesia: a pilot study. Rom J Anaesth Intensive Care. 2018;25(1):19–23.PubMedPubMedCentral

19.

Lukaszewicz AC, Dereu D, Gayat E, Payen D. The relevance of pupillometry for evaluation of analgesia before noxious procedures in the intensive care unit. Anesth Analg. 2015;120(6):1297–300.PubMed

20.

Anderson CD, James ML. Survival and independence after intracerebral hemorrhage: trends and opportunities. Neurology. 2018;90(23):1043–4.PubMed

21.

Suys T, Bouzat P, Marques-Vidal P, Sala N, Payen JF, Rossetti AO, et al. Automated quantitative pupillometry for the prognostication of coma after cardiac arrest. Neurocrit Care. 2014;21(2):300–8.PubMed

22.

McNett M, Moran C, Grimm D, Gianakis A. Pupillometry trends in the setting of increased intracranial pressure. J Neurosci Nurs. 2018;50(6):357–61.PubMed

23.

McNett M, Moran C, Janki C, Gianakis A. Correlations between hourly pupillometer readings and intracranial pressure values. J Neurosci Nurs. 2017;49(4):229–34.PubMed

24.

Papangelou A, Zink EK, Chang WW, Frattalone A, Gergen D, Gottschalk A, et al. Automated pupillometry and detection of clinical transtentorial brain herniation: a case series. Mil Med. 2018;183(1–2):e113–e21.PubMed

25.

Kim HM, Yang HK, Hwang JM. Quantitative analysis of pupillometry in isolated third nerve palsy. PLoS One. 2018;13(11):e0208259.PubMedPubMedCentral

26.

Oddo M, Sandroni C, Citerio G, Miroz JP, Horn J, Rundgren M, et al. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study. Intensive Care Med. 2018;44(12):2102–11.PubMedPubMedCentral

27.

Solari D, Rossetti AO, Carteron L, Miroz JP, Novy J, Eckert P, et al. Early prediction of coma recovery after cardiac arrest with blinded pupillometry. Ann Neurol. 2017;81(6):804–10.PubMed

28.

Lee MH, Mitra B, Pui JK, Fitzgerald M. The use and uptake of pupillometers in the intensive care unit. Aust Crit Care. 2018;31(4):199–203.PubMed

29.

Phillips SS, Mueller CM, Nogueira RG, Khalifa YM. A systematic review assessing the current state of automated pupillometry in the NeuroICU. Neurocrit Care. 2019;31(1):142–61.PubMed

30.

Wilson SAK. Ectopia pupillae in certain mesencephalic lesions. Brain : a journal of neurology. 1907;29(4):524–36.

31.

Fisher CM. Oval pupils. Arch Neurol. 1980;37(8):502–3.PubMed

32.

Marshall LF, Barba D, Toole BM, Bowers SA. The oval pupil: clinical significance and relationship to intracranial hypertension. J Neurosurg. 1983;58(4):566–8.PubMed

33.

Taylor WR, Chen JW, Meltzer H, Gennarelli TA, Kelbch C, Knowlton S, et al. Quantitative pupillometry, a new technology: normative data and preliminary observations in patients with acute head injury. Technical note. J Neurosurg. 2003;98(1):205–13.PubMed

34.

Atchison DA, Girgenti CC, Campbell GM, Dodds JP, Byrnes TM, Zele AJ. Influence of field size on pupil diameter under photopic and mesopic light levels. Clin Exp Optom. 2011;94(6):545–8.PubMed

35.

Wang Y, Zekveld AA, Naylor G, Ohlenforst B, Jansma EP, Lorens A, et al. Parasympathetic nervous system dysfunction, as identified by pupil light reflex, and its possible connection to hearing impairment. PLoS One. 2016;11(4):e0153566.PubMedPubMedCentral

36.

Hall CA, Chilcott RP. Eyeing up the future of the pupillary light reflex in neurodiagnostics. Diagnostics (Basel). 2018;8(1).

37.

Olson DM, Fishel M. The use of automated pupillometry in critical care. Crit Care Nurs Clin North Am. 2016;28(1):101–7.PubMed

38.

Adhikari P, Zele AJ, Feigl B. The post-illumination pupil response (PIPR). Invest Ophthalmol Vis Sci. 2015;56(6):3838–49.PubMed

39.

Loewenfeld IE. Mechanisms of reflex dilatation of the pupil; historical review and experimental analysis. Doc Ophthalmol. 1958;12:185–448.PubMed

40.

Barbur JL, Moro S, Harlow JA, Lam BL, Liu M. Comparison of pupil responses to luminance and colour in severe optic neuritis. Clin Neurophysiol. 2004;115(11):2650–8.PubMed

41.

Larson MD, Behrends M. Portable infrared pupillometry: a review. Anesth Analg. 2015;120(6):1242–53.PubMed

42.

Robba C, Moro Salihovic B, Pozzebon S, Creteur J, Oddo M, Vincent JL, et al. Comparison of 2 automated pupillometry devices in critically ill patients. J Neurosurg Anesthesiol. 2019:1.

43.

Ong C, Hutch M, Smirnakis S. The effect of ambient light conditions on quantitative pupillometry. Neurocrit Care. 2019;30(2):316–21.PubMed

44.

Park JG, Moon CT, Park DS, Song SW. Clinical utility of an automated pupillometer in patients with acute brain lesion. J Korean Neurosurg Soc. 2015;58(4):363–7.PubMedPubMedCentral

45.

Olson DM, Ortega-Perez S. The cue-response theory and nursing care of the patient with acquired brain injury. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses. 2018;51(1):43–7.

46.

Kasprowicz M, Burzynska M, Melcer T, Kubler A. A comparison of the Full Outline of UnResponsiveness (FOUR) score and Glasgow Coma Score (GCS) in predictive modelling in traumatic brain injury. Br J Neurosurg. 2016;30(2):211–20.PubMed

47.

Thiagarajan P, Ciuffreda KJ. Pupillary responses to light in chronic non-blast-induced mTBI. Brain Inj. 2015;29(12):1420–5.PubMed

48.

Cohen JE, Montero A, Israel ZH. Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma. 1996;41(1):120–2.PubMed

49.

Lieberman JD, Pasquale MD, Garcia R, Cipolle MD, Mark Li P, Wasser TE. Use of admission Glasgow Coma Score, pupil size, and pupil reactivity to determine outcome for trauma patients. J Trauma. 2003;55(3):437–42 discussion 42-3.PubMed

50.

Stevens AR, Su Z, Toman E, Belli A, Davies D. Optical pupillometry in traumatic brain injury: neurological pupil index and its relationship with intracranial pressure through significant event analysis. Brain Inj. 2019;33(8):1032–8.PubMed

51.

Soeken TA, Alonso A, Grant A, Calvillo E, Gutierrez-Flores B, Clark J, et al. Quantitative pupillometry for detection of intracranial pressure changes during head-down tilt. Aerospace medicine and human performance. 2018;89(8):717–23.PubMed

52.

Aoun SG, Welch B, Cortes M. Objective pupillometry as an adjunct to prediction and assessment for oculomotor nerve injury and recovery: potential for practical applications. World Neurosurg. 2018.

53.

Yoo YJ, Yang HK, Hwang JM. Efficacy of digital pupillometry for diagnosis of Horner syndrome. PLoS One. 2017;12(6):e0178361.PubMedPubMedCentral

54.

Peinkhofer C, Martens P, Grand J, Truelsen T, Knudsen GM, Kjaergaard J, et al. Influence of strategic cortical infarctions on pupillary function. Front Neurol. 2018;9:916.PubMedPubMedCentral

55.

Shirozu K, Murayama K, Karashima Y, Setoguchi H, Miura T, Hoka S. The relationship between seizure in electroconvulsive therapy and pupillary response using an automated pupilometer. J Anesth. 2018;32(6):866–71.PubMed

56.

Larson MD, Muhiudeen I. Pupillometric analysis of the ‘absent light reflex’. Arch Neurol. 1995;52(4):369–72.PubMed

57.

Olgun G, Newey CR, Ardelt A. Pupillometry in brain death: differences in pupillary diameter between paediatric and adult subjects. Neurol Res. 2015;37(11):945–50.PubMed

58.

Yokobori S, Wang KKK, Yang Z, Zhu T, Tyndall JA, Mondello S, et al. Quantitative pupillometry and neuron-specific enolase independently predict return of spontaneous circulation following cardiogenic out-of-hospital cardiac arrest: a prospective pilot study. Sci Rep. 2018;8(1):15964.PubMedPubMedCentral

59.

• Tamura T, Namiki J, Sugawara Y, Sekine K, Yo K, Kanaya T, et al. Quantitative assessment of pupillary light reflex for early prediction of outcomes after out-of-hospital cardiac arrest: a multicentre prospective observational study. Resuscitation. 2018;131:108–13 Small but provocative study correlating very early quantitative pupillometry findings with neurologic outcomes after cardiac arrest. PubMed

60.

Obling L, Hassager C, Illum C, Grand J, Wiberg S, Lindholm MG, et al. Prognostic value of automated pupillometry: an unselected cohort from a cardiac intensive care unit. Eur Heart J Acute Cardiovasc Care. 2019;2048872619842004.

61.

Beuchat I, Solari D, Novy J, Oddo M, Rossetti AO. Standardized EEG interpretation in patients after cardiac arrest: correlation with other prognostic predictors. Resuscitation. 2018;126:143–6.PubMed

62.

Heimburger D, Durand M, Gaide-Chevronnay L, Dessertaine G, Moury PH, Bouzat P, et al. Quantitative pupillometry and transcranial Doppler measurements in patients treated with hypothermia after cardiac arrest. Resuscitation. 2016;103:88–93.PubMed

63.

• Solari D, Miroz J-P, Oddo M. Opening a window to the injured brain: non-invasive neuromonitoring with quantitative pupillometry. In: Vincent J-L, editor. Annual update in intensive care and emergency medicine 2018. Cham: Springer international publishing; 2018. p. 503–18. One of the largest recent prospective studies to assess utility of quantitative automated pupillometry in predicting neurologic outcome after cardiac arrest compared with other prediction tools.

64.

Behrends M, Larson MD, Neice AE, Bokoch MP. Suppression of pupillary unrest by general anesthesia and propofol sedation. J Clin Monit Comput. 2019;33(2):317–23.PubMed

65.

Larson MD, Sessler DI. Pupillometry to guide postoperative analgesia. Anesthesiology. 2012;116(5):980–2.PubMed

66.

Lobato-Rincon LL, Cabanillas Campos MC, Navarro-Valls JJ, Bonnin-Arias C, Chamorro E, Sanchez-Ramos RC. Utility of dynamic pupillometry in alcohol testing on drivers. Adicciones. 2013;25(2):137–45.PubMed

67.

Hysek CM, Liechti ME. Effects of MDMA alone and after pretreatment with reboxetine, duloxetine, clonidine, carvedilol, and doxazosin on pupillary light reflex. Psychopharmacology. 2012;224(3):363–76.PubMed

68.

Hartman RL, Richman JE, Hayes CE, Huestis MA. Drug Recognition Expert (DRE) examination characteristics of cannabis impairment. Accid Anal Prev. 2016;92:219–29.PubMed

69.

Hou RH, Scaife J, Freeman C, Langley RW, Szabadi E, Bradshaw CM. Relationship between sedation and pupillary function: comparison of diazepam and diphenhydramine. Br J Clin Pharmacol. 2006;61(6):752–60.PubMedPubMedCentral

70.

Artigas C, Redondo JI, Lopez-Murcia MM. Effects of intravenous administration of dexmedetomidine on intraocular pressure and pupil size in clinically normal dogs. Vet Ophthalmol. 2012;15(Suppl 1):79–82.PubMed

71.

Larson MD, Talke PO. Effect of dexmedetomidine, an alpha2-adrenoceptor agonist, on human pupillary reflexes during general anaesthesia. Br J Clin Pharmacol. 2001;51(1):27–33.PubMedPubMedCentral

72.

Akkaya S, Kokcen HK, Atakan T. Unilateral transient mydriasis and ptosis after botulinum toxin injection for a cosmetic procedure. Clin Ophthalmol. 2015;9:313–5.PubMedPubMedCentral

73.

Bertrand AL, Garcia JB, Viera EB, Santos AM, Bertrand RH. Pupillometry: the influence of gender and anxiety on the pain response. Pain Physician. 2013;16(3):E257–66.PubMed

74.

Larson MD, Berry PD. Supraspinal pupillary effects of intravenous and epidural fentanyl during isoflurane anesthesia. Reg Anesth Pain Med. 2000;25(1):60–6.PubMed

75.

Guglielminotti J, Mentre F, Gaillard J, Ghalayini M, Montravers P, Longrois D. Assessment of pain during labor with pupillometry: a prospective observational study. Anesth Analg. 2013;116(5):1057–62.PubMedPubMedCentral

76.

Paulus J, Roquilly A, Beloeil H, Theraud J, Asehnoune K, Lejus C. Pupillary reflex measurement predicts insufficient analgesia before endotracheal suctioning in critically ill patients. Critical care (London, England). 2013;17(4):R161.PubMedPubMedCentral

77.

Kantor E, Montravers P, Longrois D, Guglielminotti J. Pain assessment in the postanaesthesia care unit using pupillometry: a cross-sectional study after standard anaesthetic care. Eur J Anaesthesiol. 2014;31(2):91–7.PubMed

78.

Aissou M, Snauwaert A, Dupuis C, Atchabahian A, Aubrun F, Beaussier M. Objective assessment of the immediate postoperative analgesia using pupillary reflex measurement: a prospective and observational study. Anesthesiology. 2012;116(5):1006–12.PubMed

79.

Wildemeersch D, Gios J, Jorens PG, Hans GH. Objective nociceptive assessment in ventilated ICU patients: a feasibility study using pupillometry and the nociceptive flexion reflex. J Vis Exp. 2018;137.

80.

Sabourdin N, Peretout JB, Khalil E, Guye ML, Louvet N, Constant I. Influence of depth of hypnosis on pupillary reactivity to a standardized tetanic stimulus in patients under propofol-remifentanil target-controlled infusion: a crossover randomized pilot study. Anesth Analg. 2018;126(1):70–7.PubMed

81.

Silva CRG, Goncalves C, Camilo ENR, Boaretti Dos Santos F, Siqueira J, de Albuquerque ES, et al. Automated evaluation system for human pupillary behavior. Stud Health Technol Inform. 2017;245:589–93.PubMed

82.

Bartosova O, Bonnet C, Ulmanova O, Sima M, Perlik F, Ruzicka E, et al. Pupillometry as an indicator of L-DOPA dosages in Parkinson’s disease patients. J Neural Transm (Vienna). 2018;125(4):699–703.

83.

Park HL, Jung SH, Park SH, Park CK. Detecting autonomic dysfunction in patients with glaucoma using dynamic pupillometry. Medicine (Baltimore). 2019;98(11):e14658.

84.

Wagner JB, Luyster RJ, Tager-Flusberg H, Nelson CA. Greater pupil size in response to emotional faces as an early marker of social-communicative difficulties in infants at high risk for autism. Infancy. 2016;21(5):560–81.PubMedPubMedCentral

85.

Nystrom P, Gliga T, Nilsson Jobs E, Gredeback G, Charman T, Johnson MH, et al. Enhanced pupillary light reflex in infancy is associated with autism diagnosis in toddlerhood. Nat Commun. 2018;9(1):1678.PubMedPubMedCentral

Title: Automated Pupillometry in Neurocritical Care: Research and Practice
Authors: Bethany L. Lussier
DaiWai M. Olson
Venkatesh Aiyagari
Publication date: 01-10-2019
Publisher: Springer US
Keywords: Central Nervous System Trauma
Neurological Tests
Intracranial Hypertension
Care
Published in: Current Neurology and Neuroscience Reports / Issue 10/2019
Print ISSN: 1528-4042
Electronic ISSN: 1534-6293
DOI: https://doi.org/10.1007/s11910-019-0994-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Automated Pupillometry in Neurocritical Care: Research and Practice

Abstract

Purpose of Review

Recent Findings

Summary

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

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