Infrared pupillometry, the Neurological Pupil index and unilateral pupillary dilation after traumatic brain injury: implications for treatment paradigms

IntroductionThe pupillary examination is an important part of the neurological assessment, especially in the setting of acutely brain-injured patients, and pupillary abnormalities are associated with poor outcomes. Currently, the pupillary examination is based on a visual, subjective and frequently inaccurate estimation. The use of automated infrared pupillometry to measure the pupillary light reflex can precisely quantify subtle changes in pupillary functions. The study aimed to evaluate the association between abnormal pupillary function, assessed by the Neurological Pupil Index (NPi), and long-term outcomes in patients with acute brain injury (ABI).Methods and analysisThe Outcome Prognostication of Acute Brain Injury using the Neurological Pupil Index study is a prospective, observational study including adult patients with ABI requiring admission at the intensive care unit. We aimed to recruit at least 420 patients including those suffering from traumatic brain injury or haemorrhagic strokes, over 12 months. The primary aim was to assess the relationship between NPi and 6-month mortality or poor neurological outcome, measured by the Extended Glasgow Outcome Score (GOS-E, poor outcome=GOS-E 1–4). Supervised and unsupervised methods and latent class mixed models will be used to identify patterns of NPi trajectories and Cox and logistic model to evaluate their association with outcome.Ethics and disseminationThe study has been approved by the institutional review board (Comitato Etico Brianza) on 16 July 2020. Approved protocol V.4.0 dated 10 March 2020. The results of this study will be published in peer-reviewed journals and presented at conferences.Trial registration numberNCT04490005.

Download Full-text

Osteopathic Manipulative Treatment to Optimize the Glymphatic Environment in Severe Traumatic Brain Injury Measured With Optic Nerve Sheath Diameter, Intracranial Pressure Monitoring, and Neurological Pupil Index

Cureus ◽

10.7759/cureus.13823 ◽

2021 ◽

Author(s):

Samir Kashyap ◽

James Brazdzionis ◽

Paras Savla ◽

James A Berry ◽

Saman Farr ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Optic Nerve ◽

Intracranial Pressure ◽

Severe Traumatic Brain Injury ◽

Optic Nerve Sheath Diameter ◽

Osteopathic Manipulative Treatment ◽

Pressure Monitoring ◽

Nerve Sheath ◽

Neurological Pupil Index

Download Full-text

Optical pupillometry in traumatic brain injury: neurological pupil index and its relationship with intracranial pressure through significant event analysis

Brain Injury ◽

10.1080/02699052.2019.1605621 ◽

2019 ◽

Vol 33 (8) ◽

pp. 1032-1038 ◽

Cited By ~ 6

Author(s):

A. R. Stevens ◽

Z. Su ◽

E. Toman ◽

A. Belli ◽

D. Davies

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Event Analysis ◽

Neurological Pupil Index

Download Full-text

Early Pupillometry Assessment in Traumatic Brain Injury Patients: A Retrospective Study

Brain Sciences ◽

10.3390/brainsci11121657 ◽

2021 ◽

Vol 11 (12) ◽

pp. 1657

Author(s):

Thomas Luz Teixeira ◽

Lorenzo Peluso ◽

Pierluigi Banco ◽

Hassane Njimi ◽

Layal Abi-Khalil ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Retrospective Study ◽

Brain Injury ◽

Neurological Outcome ◽

Generalized Linear Model ◽

Prognostic Value ◽

Prognostic Role ◽

Early Assessment ◽

Neurological Pupil Index

Background: The aim of this study was to evaluate whether the early assessment of neurological pupil index (NPi) values derived from automated pupillometry could predict neurological outcome after traumatic brain injury (TBI). Methods: Retrospective observational study including adult (>18 years) TBI patients admitted from January 2018 to December 2020, with available NPi on admission. Abnormal NPi was considered if <3. Unfavorable neurological outcome (UO) at hospital discharge was considered for a Glasgow Outcome Scale of 1–3. Results: 100 patients were included over the study period (median age 48 (34–69) years and median GCS on admission 11 (6–15)); 49 (49%) patients had UO. On admission, 20 (20%) patients had an abnormal NPi (NPi < 3); median worst (i.e., from both eyes) NPi was 4.2 (3.2–4.5). Median worst and mean NPi on admission were significantly lower in the UO group than others (3.9 (1.7–4.4) vs. 4.4 (3.7–4.6); p = 0.005–4.0 (2.6–4.5) vs. 4.5 (3.9–4.7); p = 0.002, respectively). The ROC curve for the worst and mean NPi showed a moderate accuracy to predict UO (AUC 0.66 (0.56–0.77); p = 0.005 and 0.68 (0.57–0.78); p = 0.002). However, in a generalized linear model, the prognostic role of NPi on admission was limited. Conclusions: Low NPi on admission has limited prognostic value in TBI.

Download Full-text

Mobile Digital Pupillometry for Rapid Triage of Patients With Severe Traumatic Brain Injury

Neurosurgery ◽

10.1093/neuros/nyz310_844 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Lynn B McGrath ◽

Jessica C Eaton ◽

Anthony Law ◽

Alex Mariakakis ◽

Shwetak Patel ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Excess Mortality ◽

The United States ◽

Substantial Improvement ◽

National Study ◽

Pupillary Light ◽

Infrared Pupillometry ◽

Severe Tbi ◽

Ed Visits

Abstract INTRODUCTION Traumatic brain injury (TBI) is the leading cause of mortality in people under age 45 and accounts for 2.5 million ED visits and $75 billion in healthcare costs each year in the United States. The key to ensuring the best possible clinical outcome for TBI patients is to facilitate their care at a designated trauma center. Unfortunately, up to 60% of severe TBI patients are undertriaged and admitted to non-trauma hospitals, a systemic problem which the National Study on the Costs and Outcomes of Trauma has demonstrated results in an excess mortality of 25%. Evaluation of the pupillary light reflex (PLR) is a crucial factor in triaging TBI patients, but penlight-based manual pupillometry is known to be inaccurate and digital infrared pupillometry impractical for field use. PupilScreen, a pupillometry technology developed for smartphones, integrates the convenience of manual pupillometry with the accuracy of a digital infrared pupillometer and may represent a practical way to improve the triage of severe TBI patients. METHODS A smartphone-based pupillometer, PupilScreen, was developed utilizing a fully convolutional neural network (FCNN) and the flash and camera from a typical iPhone. The FCNN was trained for 175 000 iterations on a database consisting of 4410 pupil image samples from 42 healthy volunteers and 7 TBI patients. Once sufficient accuracy in generating PLR curves was achieved (0.3 mm mean error in diameter estimation), the trained network analyzed n = 48 new samples (n = 24 from healthy patients and n = 24 from patients with severe TBI [GCS < 8]). PLR curves were generated for each cohort and presented to 2 blinded clinicians to assess each pupil as either “responsive” or “non-responsive”. RESULTS When presented with PLR curves, one blinded clinician was able to correctly classify a patient as demonstrating “responsive” or “non-responsive” pupils with 100% accuracy, and the other with 99% accuracy (one “non-responsive” curve was misclassified as “responsive”). While limited in scope, these results demonstrate substantial improvement over manual pupillometry. CONCLUSION A smartphone-based pupillometer can provide PLR assessments accurate and intuitive enough for clinicians to identify one of the clinical hallmarks of TBI, and may be useful for patient triage.

Download Full-text

Cognitive control constrains memory attributions

Behavioral and Brain Sciences ◽

10.1017/s0140525x19001869 ◽

2019 ◽

Vol 42 ◽

Author(s):

Colleen M. Kelley ◽

Larry L. Jacoby

Keyword(s):

Alzheimer’S Disease ◽

Older Adults ◽

Alzheimer's Disease ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Cognitive Control

Abstract Cognitive control constrains retrieval processing and so restricts what comes to mind as input to the attribution system. We review evidence that older adults, patients with Alzheimer's disease, and people with traumatic brain injury exert less cognitive control during retrieval, and so are susceptible to memory misattributions in the form of dramatic levels of false remembering.

Download Full-text

Lessons Learned From Coaching Postsecondary Students With Traumatic Brain Injury

Perspectives of the ASHA Special Interest Groups ◽

10.1044/2019_persp-19-00092 ◽

2020 ◽

Vol 5 (1) ◽

pp. 88-96

Author(s):

Mary R. T. Kennedy

Keyword(s):

College Students ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Sense Of Self ◽

Scientific Evidence ◽

Sudden Onset ◽

Lessons Learned ◽

Speech Language Pathologists ◽

The Brain ◽

Exhaustive List

Purpose The purpose of this clinical focus article is to provide speech-language pathologists with a brief update of the evidence that provides possible explanations for our experiences while coaching college students with traumatic brain injury (TBI). Method The narrative text provides readers with lessons we learned as speech-language pathologists functioning as cognitive coaches to college students with TBI. This is not meant to be an exhaustive list, but rather to consider the recent scientific evidence that will help our understanding of how best to coach these college students. Conclusion Four lessons are described. Lesson 1 focuses on the value of self-reported responses to surveys, questionnaires, and interviews. Lesson 2 addresses the use of immediate/proximal goals as leverage for students to update their sense of self and how their abilities and disabilities may alter their more distal goals. Lesson 3 reminds us that teamwork is necessary to address the complex issues facing these students, which include their developmental stage, the sudden onset of trauma to the brain, and having to navigate going to college with a TBI. Lesson 4 focuses on the need for college students with TBI to learn how to self-advocate with instructors, family, and peers.

Download Full-text

The Speech-Language Pathologists' Role in Mild Traumatic Brain Injury for Middle and High School–Age Children: Viewpoints on Guidelines From the Centers for Disease Control and Prevention

American Journal of Speech-Language Pathology ◽

10.1044/2019_ajslp-18-0296 ◽

2019 ◽

Vol 28 (3) ◽

pp. 1363-1370 ◽

Cited By ~ 2

Author(s):

Jessica Brown ◽

Katy O'Brien ◽

Kelly Knollman-Porter ◽

Tracey Wallace

Keyword(s):

High School ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Disease Control ◽

Mild Traumatic Brain Injury ◽

School Age Children ◽

School Age ◽

Speech Language Pathologists ◽

Control And Prevention ◽

Centers For Disease Control

Purpose The Centers for Disease Control and Prevention (CDC) recently released guidelines for rehabilitation professionals regarding the care of children with mild traumatic brain injury (mTBI). Given that mTBI impacts millions of children each year and can be particularly detrimental to children in middle and high school age groups, access to universal recommendations for management of postinjury symptoms is ideal. Method This viewpoint article examines the CDC guidelines and applies these recommendations directly to speech-language pathology practices. In particular, education, assessment, treatment, team management, and ongoing monitoring are discussed. In addition, suggested timelines regarding implementation of services by speech-language pathologists (SLPs) are provided. Specific focus is placed on adolescents (i.e., middle and high school–age children). Results SLPs are critical members of the rehabilitation team working with children with mTBI and should be involved in education, symptom monitoring, and assessment early in the recovery process. SLPs can also provide unique insight into the cognitive and linguistic challenges of these students and can serve to bridge the gap among rehabilitation and school-based professionals, the adolescent with brain injury, and their parents. Conclusion The guidelines provided by the CDC, along with evidence from the field of speech pathology, can guide SLPs to advocate for involvement in the care of adolescents with mTBI. More research is needed to enhance the evidence base for direct assessment and treatment with this population; however, SLPs can use their extensive knowledge and experience working with individuals with traumatic brain injury as a starting point for post-mTBI care.

Download Full-text