Neurological Pupil Index for the Early Prediction of Outcome in Severe Acute Brain Injury Patients

In this study, we examined the early value of automated quantitative pupillary examination, using the Neurological Pupil index (NPi), to predict the long-term outcome of acute brain injured (ABI) patients. We performed a single-centre retrospective study (October 2016–March 2019) in ABI patients who underwent NPi measurement during the first 3 days following brain insult. We examined the performance of NPi—alone or in combination with other baseline demographic (age) and radiologic (CT midline shift) predictors—to prognosticate unfavourable 6-month outcome (Glasgow Outcome Scale 1–3). A total of 145 severely brain-injured subjects (65 traumatic brain injury, TBI; 80 non-TBI) were studied. At each time point tested, NPi <3 was highly predictive of unfavourable outcome, with highest specificity (100% (90–100)) at day 3 (sensitivity 24% (15–35), negative predictive value 36% (34–39)). The addition of NPi, from day 1 following ABI to age and cerebral CT scan, provided the best prognostic performance (AUROC curve 0.85 vs. 0.78 without NPi, p = 0.008; DeLong test) for 6-month neurological outcome prediction. NPi, assessed at the early post-injury phase, has a superior ability to predict unfavourable long-term neurological outcomes in severely brain-injured patients. The added prognostic value of NPi was most significant when complemented with baseline demographic and radiologic information.

[1]  G. Citerio,et al.  Outcome Prognostication of Acute Brain Injury using the Neurological Pupil Index (ORANGE) study: protocol for a prospective, observational, multicentre, international cohort study , 2021, BMJ Open.

[2]  J. Soar,et al.  European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. , 2021, Resuscitation.

[3]  J. Ghajar,et al.  In Reply: Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations. , 2020, Neurosurgery.

[4]  Hester F. Lingsma,et al.  Clinical characteristics and outcomes in patients with traumatic brain injury in China: a prospective, multicentre, longitudinal, observational study , 2020, The Lancet Neurology.

[5]  D. Seder,et al.  Neurological Pupil Index and Pupillary Light Reflex by Pupillometry Predict Outcome Early After Cardiac Arrest , 2020, Neurocritical care.

[6]  Mayur B. Patel,et al.  A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) , 2020, Intensive Care Medicine.

[7]  Daiwai M. Olson,et al.  Detection of delayed cerebral ischemia using objective pupillometry in patients with aneurysmal subarachnoid hemorrhage. , 2020, Journal of neurosurgery.

[8]  John K. Yue,et al.  Long-term outcome in traumatic brain injury patients with midline shift: a secondary analysis of the Phase 3 COBRIT clinical trial. , 2019, Journal of neurosurgery.

[9]  F. Taccone,et al.  Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury , 2019, Critical Care.

[10]  M. Oddo,et al.  Role of automated pupillometry in critically ill patients. , 2019, Minerva anestesiologica.

[11]  J. Payen,et al.  Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study , 2018, Intensive Care Medicine.

[12]  H. Yokota,et al.  Quantitative assessment of pupillary light reflex for early prediction of outcomes after out-of-hospital cardiac arrest: A multicentre prospective observational study. , 2018, Resuscitation.

[13]  K. Ghaemi,et al.  Marshall and Rotterdam Computed Tomography scores in predicting early deaths after brain trauma , 2018, European journal of translational myology.

[14]  Odette A. Harris,et al.  Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition , 2016, Neurosurgery.

[15]  Douglas G. Altman,et al.  Updating standards for reporting diagnostic accuracy: the development of STARD 2015 , 2016, Research Integrity and Peer Review.

[16]  Daiwai M. Olson,et al.  Interrater Reliability of Pupillary Assessments , 2016, Neurocritical Care.

[17]  L. Velly,et al.  Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study , 2016, Critical Care.

[18]  J. Nolan,et al.  Post-resuscitation care: ERC–ESICM guidelines 2015 , 2015, Intensive Care Medicine.

[19]  Mario Zuccarello,et al.  Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2015, Stroke.

[20]  M. Behrends,et al.  Portable Infrared Pupillometry: A Review , 2015, Anesthesia and analgesia.

[21]  Hester F. Lingsma,et al.  Glasgow coma scale motor score and pupillary reaction to predict six-month mortality in patients with traumatic brain injury: comparison of field and admission assessment. , 2015, Journal of neurotrauma.

[22]  N. King,et al.  External validation of the CRASH and IMPACT prognostic models in severe traumatic brain injury. , 2014, Journal of neurotrauma.

[23]  E. Connolly,et al.  Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2012, Stroke.

[24]  R. Bullock,et al.  Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index , 2011, Surgical neurology international.

[25]  R. Birgander,et al.  The Fisher grading correlated to outcome in patients with subarachnoid haemorrhage , 2009, British journal of neurosurgery.

[26]  Juan Lu,et al.  Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. , 2007, Journal of neurotrauma.

[27]  P. Fatouros,et al.  Brain stem blood flow, pupillary response, and outcome in patients with severe head injuries. , 1999, Neurosurgery.

[28]  R. Chesnut,et al.  The localizing value of asymmetry in pupillary size in severe head injury: relation to lesion type and location. , 1994, Neurosurgery.

[29]  E. DeLong,et al.  Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. , 1988, Biometrics.

[30]  P. Sipponen,et al.  PROGNOSIS OF SEVERE BRAIN INJURY , 1970, Acta neurologica Scandinavica.

[31]  Council , 1954, The Aeronautical Journal (1968).

[32]  W. Thies,et al.  Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council, American Heart Association , 2005 .