Pupillometry in the follow-up of patients undergoing EVT - prediction of space-occupying hemispheric infarction

Abstract

Background Despite benefits of endovascular treatment (EVT) for large vessel occlusion (LVO) ischemic stroke, space-occupying brain edema (BE) represents a detrimental complication. In critical-care settings, CT-imaging is needed for monitoring these patients. Yet, bed-side techniques with the potential to predict whether patients develop BE or not would facilitate a time- and cost-efficient patient care. We assessed clinical significance of automated pupillometry in the follow-up of patients undergoing EVT. Methods From 10/2018 to 10/2021, neurocritical-care-unit patients were retrospectively enrolled after EVT of anterior circulation LVO. We monitored parameters of pupillary reactivity [light-reflex-latency (Lat), constriction- and redilation-velocities (CV, DV), percentage-change-of-apertures (per-change); NeurOptics-pupilometer®] up to every hour on day 1–3 of ICU stay. BE was defined as midline shift ≥ 5 mm on follow-up imaging 3–5 days after EVT. We calculated mean values of intra-individual differences between successive pairs of parameters (mean-deltas), determined best discriminative cut-off values for BE development (ROC-analyses), and evaluated prognostic performance of pupillometry for BE development (sensitivity/specificity/positive-/negative-predictive-values). Results 3241 pupillary assessments of 122 patients [67 women, 73 years (61.0–85.0)] were included. 13/122 patients developed BE. Patients with BE had significantly lower CVs, DVs, and smaller per-changes than patients without BE. On day 1 after EVT mean-deltas of CV, DV, and per-changes were significantly lower in patients with than without BE. Positive-predictive-values of calculated thresholds to discriminate both groups were considerably low, yet, we found high negative-predictive-values for CV, DV, per-changes, and mean-deltas (max.: 98.4%). Conclusion Our data suggest associations between noninvasively detected changes in pupillary reactivity and BE early after LVO-EVT. Pupillometry may identify patients who are unlikely to develop BE and may not need repetitive follow-up-imaging or rescue-therapy.

Automated Pupillometry Is Able to Discriminate Patients with Acute Stroke from Healthy Subjects: An Observational, Cross-Sectional Study

“…To date, no studies have analyzed the ability of AP to discriminate AIS patients from HS. The limited evidence focusing on patients with AIS confirmed that AP can detect sudden clinical/radiological worsening early, suggestive of intracranial hypertension in such populations [ 17 , 18 , 32 , 33 ]. A reduction in mean overall CV, DV, and CH [ 17 ], or at least one NPi < 3 [ 32 ], predicted the development of radiological/clinical evidence of brain edema in patients who underwent mechanical thrombectomy.…”

“…The limited evidence focusing on patients with AIS confirmed that AP can detect sudden clinical/radiological worsening early, suggestive of intracranial hypertension in such populations [ 17 , 18 , 32 , 33 ]. A reduction in mean overall CV, DV, and CH [ 17 ], or at least one NPi < 3 [ 32 ], predicted the development of radiological/clinical evidence of brain edema in patients who underwent mechanical thrombectomy. Similarly, at least one NPi value < 2.8 was able to predict neurological worsening in patients with large hemispheric ischemic/hemorrhagic strokes of the anterior circulation [ 33 ].…”

“…To date, few data are available about the role of AP assessment in patients with acute stroke. Several studies focusing on the AP’s ability to detect stroke-related intracranial hypertension [ 16 , 17 , 18 ] neglected to analyze the mechanisms underlying the alteration of the PLR circuit, which can be involved due to ischemic damage. Furthermore, ischemic stroke, in the acute phase, is often associated with a cardiovascular autonomic imbalance [ 19 ], which is associated with a worse prognosis [ 20 ].…”

Dynamically Normalized Pupillometry for Detecting Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

“…The constriction velocity (CV) in response to a standardized light stimulus represents a quantitative measure of pupillary reactivity as assessed in the classical neurological examination. CV has been shown to correlate with clinical outcome after cardiac arrest (18, 19) as well as with space-occupying edema, midline shift, and intracranial pressure after neurovascular and traumatic neurological injury (15, 20, 21). Both CV and inter-eye differences in NPi have been used to predict the occurrence of delirium in acute care units (22, 23).…”