Automated Pupillometry Identifies Absence of Intracranial Pressure Elevation in Intracerebral Hemorrhage Patients.
Automated Pupillometry Identifies Absence of Intracranial Pressure Elevation in Intracerebral Hemorrhage Patients.
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DOI：
10.1007/s12028-020-01146-4
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发表时间：
2021-08
影响因子：
3.5
通讯作者：
Koehn J
中科院分区：
文献类型：
--
作者：
Giede-Jeppe A;Sprügel MI;Huttner HB;Borutta M;Kuramatsu JB;Hoelter P;Engelhorn T;Schwab S;Koehn J
虽然自动瞳孔测量在重症监护环境中的应用越来越多，但在不同的颅内压(ICP)水平下自动评估的瞳孔参数的预测价值和可能的临床意义尚未确定。这项在纽伦堡大学神经重症监护室进行的回顾性队列研究(2016-2018)包括23例非外伤性幕上(脑出血)脑出血患者，经人工评估无瞳孔功能异常体征，即无光反射。我们使用便携式瞳孔测量仪(NeurOptics®)同时通过脑室外引流和瞳孔反应性参数[即最大和最小孔径、光反射潜伏期(LAT)、收缩和矫正速度(CV、DV)和孔径变化百分比(每次变化)]来评估颅内压水平。分析CT扫描以确定病变的位置、大小、脑室内出血、脑积水、中线移位和基底池受压或缺失。我们进行了受试者工作特性分析，以调查颅内压水平与瞳孔参数的关系，并确定预测颅内压升高的最佳临界值。根据ICP值(正常： 20 mm Hg，升高：≥ 20 mm Hg)进行二分法评估后，通过计算敏感度、特异度、阳性预测值和阴性预测值(Logistic回归，95%CI对应的OR)，分析所确定的瞳孔功能截止参数与CT影像结果的预后表现。在23名患者(11名女性，中位年龄59.0(51.0-69.0)岁)中，有1,934项评估可供分析。7名患者共有74次颅内压升高， ≥ 为20毫米汞柱。对颅内压升高的最佳判别阈值为：CV <； 0.8m m/S(AUC 0.740)，每次变化 <； 10%(AUC 0.743)，DV <； 0.2m m/S(AUC 0.703)，Lat >； 0.3%S(AUC 0.616)。提示颅内压升高的所有四个参数的阳性预测值仅在7.2%至8.3%之间，对CT异常的阳性预测值也同样低(9.1%)。我们发现瞳孔参数[CV：99.2%(95%CI 98.3-99.6)，每次变化：98.7%(95%CI 97.8-99.2)，DV：98.0%(95%CI 97.0-98.7)，LAT：97.0%(95%CI 96.0-97.7)]和CT异常[99.7%(95%CI 99.2-99.9)]有很高的阴性预测值，这两种技术都能很好地诊断没有颅内压升高的脑出血患者。我们的数据表明，在服用镇静剂的脑出血患者中，非侵入性检测到的瞳孔反应性变化与颅内压水平之间存在关联。尽管自动瞳孔测量和神经成像似乎不足以无创性地提示颅内压升高，但这两种技术都能充分识别没有颅内压升高的脑出血患者。这一发现可能有助于常规治疗，省去了使用特定自动斜度测量读数的患者的侵入性颅内压监测或重复CT对照。
Although automated pupillometry is increasingly used in critical care settings, predictive value of automatically assessed pupillary parameters during different intracranial pressure (ICP) levels and possible clinical implications are unestablished. This retrospective cohort study at the neurocritical care unit of the University of Erlangen-Nuremberg (2016–2018) included 23 nontraumatic supratentorial (intracerebral hemorrhage) ICH patients without signs of abnormal pupillary function by manual assessment, i.e., absent light reflex. We assessed ICP levels by an external ventricular drain simultaneously with parameters of pupillary reactivity [i.e., maximum and minimum apertures, light reflex latency (Lat), constriction and redilation velocities (CV, DV), and percentage change of apertures (per-change)] using a portable pupillometer (NeurOptics®). Computed tomography (CT) scans were analyzed to determine lesion location, size, intraventricular hemorrhage, hydrocephalus, midline shift, and compression or absence of the basal cisterns. We performed receiver operating characteristics analysis to investigate associations of ICP levels with pupillary parameters and to determine best cutoff values for prediction of ICP elevation. After dichotomization of assessments according to ICP values (normal: < 20 mmHg, elevated: ≥ 20 mmHg), prognostic performance of the determined cutoff parameters of pupillary function versus of CT-imaging findings was analyzed by calculating sensitivity, specificity, positive and negative predictive values (logistic regression, corresponding ORs with 95% CIs). In 23 patients (11 women, median age 59.0 (51.0–69.0) years), 1,934 assessments were available for analysis. A total of 74 ICP elevations ≥ 20 mmHg occurred in seven patients. Best discriminative thresholds for ICP elevation were: CV < 0.8 mm/s (AUC 0.740), per-change < 10% (AUC 0.743), DV < 0.2 mm/s (AUC 0.703), and Lat > 0.3 s (AUC 0.616). Positive predictive value of all four parameters to indicate ICP elevation ranged between 7.2 and 8.3% only and was similarly low for CT abnormalities (9.1%). We found high negative predictive values of pupillary parameters [CV: 99.2% (95% CI 98.3–99.6), per-change: 98.7% (95% CI 97.8–99.2), DV: 98.0% (95% CI 97.0–98.7), Lat: 97.0% (95% CI 96.0–97.7)], and CT abnormalities [99.7% (95% CI 99.2–99.9)], providing evidence that both techniques adequately identified ICH patients without ICP elevation. Our data suggest an association between noninvasively detected changes in pupillary reactivity and ICP levels in sedated ICH patients. Although automated pupillometry and neuroimaging seem not sufficient to noninvasively indicate ICP elevation, both techniques, however, adequately identified ICH patients without ICP elevation. This finding may facilitate routine management by saving invasive ICP monitoring or repeated CT controls in patients with specific automated pupillometry readings.
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