Publications by authors named "Venkatesh Aiyagari"

67 Publications

A differential of the left eye and right eye neurological pupil index is associated with discharge modified Rankin scores in neurologically injured patients.

BMC Neurol 2022 Jul 22;22(1):273. Epub 2022 Jul 22.

Departments of Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA.

Background: Automated infrared pupillometry (AIP) and the Neurological Pupil index (NPi) provide an objective means of assessing and trending the pupillary light reflex (PLR) across a broad spectrum of neurological diseases. NPi quantifies the PLR and ranges from 0 to 5; in healthy individuals, the NPi of both eyes is expected to be ≥ 3.0 and symmetric. AIP values demonstrate emerging value as a prognostic tool with predictive properties that could allow practitioners to anticipate neurological deterioration and recovery. The presence of an NPi differential (a difference ≥ 0.7 between the left and right eye) is a potential sign of neurological abnormality.

Methods: We explored NPi differential by considering the modified Rankin Score at discharge (DC mRS) among patients admitted to neuroscience intensive care units (NSICU) of 4 U.S. and 1 Japanese hospitals and for two cohorts of brain injuries: stroke (including subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, and aneurysm, 1,200 total patients) and 185 traumatic brain injury (TBI) patients for a total of more than 54,000 pupillary measurements.

Results: Stroke patients with at least 1 occurrence of an NPi differential during their NSICU stay have higher DC mRS scores (3.9) compared to those without an NPi differential (2.7; P < .001). Patients with TBI and at least 1 occurrence of an NPi differential during their NSICU stay have higher discharge modified Rankin Scale scores (4.1) compared to those without an NPi differential (2.9; P < .001). When patients experience both abnormalities, abnormal (NPi < 3.0) and an NPi differential, the latter has an anticipatory relationship with respect to the former (P < .001 for z-score skewness analysis). Finally, our analysis confirmed ≥ 0.7 as the optimal cutoff value for the NPi differential (AUC = 0.71, P < .001).

Conclusion: The NPi differential is an important factor that clinicians should consider when managing critically ill neurological injured patients admitted to the neurocritical care units.

Trial Registration: NCT02804438 , Date of Registration: June 17, 2016.
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http://dx.doi.org/10.1186/s12883-022-02801-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9306158PMC
July 2022

Relationship Between Automated Pupillometry Measurements and Ventricular Volume in Patients With Aneurysmal Subarachnoid Hemorrhage.

J Neurosci Nurs 2022 Aug 21;54(4):166-170. Epub 2022 Jun 21.

Abstract: INTRODUCTION: Pupillometry allows for a standardized assessment of the pupillary light reflex. Acute hydrocephalus (HCP) is a common complication in patients with aneurysmal subarachnoid hemorrhage (aSAH). HCP may affect the pupillary light reflex because of increased intracranial pressure or dilation of the rostral aqueduct. The association between the pupillary light reflex and HCP in aSAH patients has not been clearly established. The objective of this study is to analyze the correlation between the Neurological Pupil index (NPi) and the degree of HCP in aSAH patients. METHODS: The Establishing Normative Data for Pupillometer Assessments in Neuroscience Intensive Care Registry is a prospectively collected database of pupillometry readings in patients admitted to 4 different neurological intensive care units. Patients in the registry with aSAH who had pupillometry assessments within 6 hours of a brain computed tomography were studied. The degree of HCP was quantified using the HCP score, and the relationship between the NPi and HCP was analyzed after controlling for confounders. RESULTS: A total of 43 patients were analyzed (mean age, 54 ± 15 years; 53.2% male; mean HCP score, 5.3 ± 3.8). Thirty-eight patients had HCP. Mean NPi for the right eye was 4.02 (±1.2), and that for the left eye was 3.7 (±1.5). After adjusting for age, sex, race, and sedation, there was no significant correlation between HCP and NPi (right eye: r = 0.12, P = .44; left eye: r = 0.04, P = .8). CONCLUSION: In patients with aSAH, NPi was not correlated with HCP score. A small sample size could be a limitation of this study. Additional studies are needed to characterize the clinical significance of pupillometry in the evaluation of patients with aSAH and HCP.
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http://dx.doi.org/10.1097/JNN.0000000000000657DOI Listing
August 2022

Posterior reversible encephalopathy syndrome in carcinoid tumor.

Proc (Bayl Univ Med Cent) 2022 19;35(4):537-539. Epub 2022 Apr 19.

Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas.

This case presents a patient with ectopic secretion of adrenocorticotrophic hormone from a carcinoid tumor resulting in severe hypertension, posterior reversible encephalopathy syndrome (PRES), and refractory status epilepticus. Secondary hypertension may be difficult to identify in critically ill patients. Severely uncontrolled hypertension presenting with PRES caused by Cushing syndrome is rare but should be considered. Management requires the correct diagnosis and specific treatment. A missed or delayed diagnosis can lead to serious consequences and disability.
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http://dx.doi.org/10.1080/08998280.2022.2057138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9196798PMC
April 2022

Neurology Exit Examination System in India: A Survey of Examiners' Perceptions and Recommendations.

Ann Indian Acad Neurol 2022 Mar-Apr;25(2):189-193. Epub 2022 Apr 6.

Department of Neurology, National Institute of Mental Health and Neurosciences, (NIMHANS), Bengaluru, Karnataka, India.

Background: The traditional Neurology exit examination in India has remained unchanged over the last few decades. In developed countries, objective evaluation methods have replaced the traditional ones. A need for such methods has not been explored in India.

Objective: We aimed to study the perceptions and key recommendations of Neurology examiners on the existing examination pattern.

Material And Methods: We conducted an online survey of examiners perceptions and recommendations using a set of 10 multiple-choice questions and an open-ended question.

Results: 46 examiners provided completed responses suitable for analysis. Nearly equal proportions (30%) of the examiners had 10 years, 10-25 years and >25 years' experience. 92% were not satisfied with current system, 95% did not find adequate time for correction of theory scripts, 90% felt that theory questions were random, and 95% had legibility issues. 84% felt that the practical exams do not test true learning, 98% felt the examination stress impairs the performance and 85% felt that there are no objective criteria to pass the candidate. 83% felt the current system-needed changes. The key suggestions provided by the examiners to improve the system included objective assessments like MCQ, OSCE, OSLER and DOPS, inclusion of larger number of short answer type questions and periodic internal assessments of the candidates.

Conclusions: A vast majority of examiners favoured changes to the current examination system and provided key recommendations. A larger study is needed to extrapolate these findings to the rest of India.
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http://dx.doi.org/10.4103/aian.aian_666_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9175401PMC
April 2022

Proceedings of the Second Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness.

Neurocrit Care 2022 08 10;37(1):326-350. Epub 2022 May 10.

Division of Anaesthesia, University of Cambridge, Cambridge, UK.

This proceedings article presents actionable research targets on the basis of the presentations and discussions at the 2nd Curing Coma National Institutes of Health (NIH) symposium held from May 3 to May 5, 2021. Here, we summarize the background, research priorities, panel discussions, and deliverables discussed during the symposium across six major domains related to disorders of consciousness. The six domains include (1) Biology of Coma, (2) Coma Database, (3) Neuroprognostication, (4) Care of Comatose Patients, (5) Early Clinical Trials, and (6) Long-term Recovery. Following the 1st Curing Coma NIH virtual symposium held on September 9 to September 10, 2020, six workgroups, each consisting of field experts in respective domains, were formed and tasked with identifying gaps and developing key priorities and deliverables to advance the mission of the Curing Coma Campaign. The highly interactive and inspiring presentations and panel discussions during the 3-day virtual NIH symposium identified several action items for the Curing Coma Campaign mission, which we summarize in this article.
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http://dx.doi.org/10.1007/s12028-022-01505-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9283342PMC
August 2022

Pilot Study of Neurologic Pupil Index as A Predictor of External Ventricular Drain Clamp Trial Failure After Subarachnoid Hemorrhage.

World Neurosurg 2022 Aug 4;164:2-7. Epub 2022 May 4.

The University of Texas Southwestern Medical Center at Dallas, Department of Neurology and Neurosurgery, Dallas, Texas, USA. Electronic address:

Background: External ventricular drains (EVDs) provide a temporary egress for cerebrospinal fluid (CSF) in patients with symptomatic hydrocephalus following aneurysmal subarachnoid hemorrhage. Before EVD removal, a wean trial, which involves clamping the EVD, is typically attempted to ensure that CSF self-regulation is achieved. Automated infrared pupillometry (AIP) has been shown to detect early neurologic decline. We sought to explore the use of AIP to detect early EVD clamping trial failure.

Methods: This prospective observational pilot study enrolled aneurysmal subarachnoid hemorrhage patients before an EVD clamp trial. On initiating the clamp trial, nurses included hourly AIP assessment in documentation. Clamp trial outcome was based on neurologic examination and neuroimaging. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) models were constructed to explore computed tomography (CT) versus AIP as predictors of clamp trial outcome.

Results: Among the 30 subjects enrolled, there were 38 clamping trials and 22 successful EVD removals. CT scan as a predictor of clamp trial was found to have a sensitivity of 68.8% and specificity of 89.5% (PPV = 84.6%, NPV = 77.3%). AIP assessment as a predictor of wean trial outcome was found to have a sensitivity of 58.3% and specificity of 100% (PPV = 100%, NPV = 63.2%).

Conclusions: The pilot study data support that Neurological Pupil index <3 is a potential indicator of early clamp trial failure, but a CT scan has a higher sensitivity and NPV for predicting successful EVD removal. This finding suggests the benefits of including AIP assessments during clamping trials.
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http://dx.doi.org/10.1016/j.wneu.2022.04.123DOI Listing
August 2022

Inter-device reliability of the NPi-200 and NPi-300 pupillometers.

J Clin Neurosci 2022 Jun 26;100:180-183. Epub 2022 Apr 26.

University of Texas Southwestern Medical Center, United States.

The pupillary evaluation is an essential part of the neurological examination. Research suggests that the traditional examination of the pupil with a handheld flashlight has limited interrater reliability. Automated pupillometers were developed to provide an objective scoring of various pupillary parameters. The NPi-200 pupillometer is used for quantitative pupillary examinations, the NPi-300 was launched in July 2021 with enhanced features. The purpose of this study is to compare results from the NPi-200 to the NPi-300 to ensure that data are translatable across both platforms. This study examines the inter-device reliability of the NPi-200 compared to the NPi-300 in two cohorts: 20 patients at risk for cerebral edema and 50 healthy controls. Paired assessments of the devices were made from all participants. Each assessment included bilateral PLR readings within a 5-minute interval. Data showed high agreement between the two devices for the Neurological Pupil Index (NPi) reading (k = 0.94; CI: 0.91-0.99) and for pupil diameter assessment (k = 0.91; CI: 0.87-0.96). There is a very high level of agreement between the NPi-200 and NPi-300 among healthy controls and critically ill patients. Clinicians and researchers can interpret the results from either device equally.
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http://dx.doi.org/10.1016/j.jocn.2022.04.023DOI Listing
June 2022

Comparison of Bispectral Index Monitor Data Between Standard Frontal-Temporal Position and Alternative Nasal Dorsum Position in the Intensive Care Unit: A Pilot Study.

J Neurosci Nurs 2022 Feb;54(1):30-34

Abstract: BACKGROUND: The Bispectral (BIS) monitor is a validated, noninvasive monitor placed over the forehead to titrate sedation in patients under general anesthesia in the operating room. In the neurocritical care unit, there is limited room on the forehead because of incisions, injuries, and other monitoring devices. This is a pilot study to determine whether a BIS nasal montage correlates to the standard frontal-temporal data in this patient population. METHODS: This prospective nonandomized pilot study enrolled 10 critically ill, intubated, and sedated adult patients admitted to the neurocritical care unit. Each patient had a BIS monitor placed over the standard frontal-temporal location and over the alternative nasal dorsum with simultaneous data collected for 24 hours. RESULTS: In the frontal-temporal location, the mean (SD) BIS score was 50.9 (15.0), average minimum BIS score was 47.0 (15.0), and average maximum BIS score was 58.4 (16.7). In the nasal dorsum location, the mean BIS score was 54.8 (21.6), average minimum BIS score was 52.8 (20.9), and average maximum BIS score was 58.0 (22.2). Baseline nonparametric tests showed nonsignificant P values for all variables except for Signal Quality Index. Generalized linear model analysis demonstrated significant differences between the 2 monitor locations (P < .0001). CONCLUSION: The results of this pilot study do not support using a BIS nasal montage as an alternative for patients in the neurocritical care unit.
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http://dx.doi.org/10.1097/JNN.0000000000000635DOI Listing
February 2022

Nimodipine in Clinical Practice: A Pharmacological Update.

J Neurosci Nurs 2022 Feb;54(1):19-22

Abstract: INTRODUCTION: Enteral nimodipine provides a neuroprotective effect in patients who have experienced an aneurysmal subarachnoid hemorrhage (aSAH). Nimodipine remains the only US Food and Drug Administration-approved medication for aSAH. CONTENT: Nimodipine has been prescribed for patients with aSAH; however, little is known about factors to consider regarding dosing or patient-specific variables that may affect tolerability to nimodipine. Clinical impact of dose or dosing frequency changes has also been much debated based on risk of hypotension with currently approved dosing regimens. CONCLUSION: This review article addresses factors to consider for dosing and administration, pharmacokinetic and pharmacogenetic impact on nimodipine, and, finally, drug interaction considerations to assess as patients are initiated on enteral nimodipine for aSAH.
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http://dx.doi.org/10.1097/JNN.0000000000000625DOI Listing
February 2022

Anisocoria Correlates With Injury Severity and Outcomes After Blunt Traumatic Brain Injury.

J Neurosci Nurs 2021 Dec;53(6):251-255

Abstract: BACKGROUND: Automated infrared pupillometry (AIP) has been shown to be helpful in the setting of aneurysmal subarachnoid hemorrhage and stroke as an indicator of imminent irreversible brain injury. We postulated that the early detection of pupillary dysfunction after light stimulation using AIP may be useful in patients with traumatic brain injury (TBI). METHODS: We performed a retrospective review of the Establishing Normative Data for Pupillometer Assessment in Neuroscience Intensive Care database, a prospectively populated multicenter registry of patients who had AIP measurements taken during their intensive care unit admission. The primary eligibility criterion was a diagnosis of blunt TBI. Ordinal logistic modeling was used to explore the association between anisocoria and daily Glasgow Coma Scale scores and discharge modified Rankin Scale scores from the intensive care unit and from the hospital. RESULTS: Among 118 subjects in the who met inclusion, there were 6187 pupillometer readings. Of these, anisocoria in ambient light was present in 12.8%, and that after light stimulation was present in 9.8%. Anisocoria after light stimulation was associated with worse injury severity (odds ratio [OR], 0.26 [95% confidence interval (CI), 0.14-0.46]), lower discharge Glasgow Coma Scale scores (OR, 0.28 [95% CI, 0.17-0.45]), and lower discharge modified Rankin Scale scores (OR, 0.28 [95% CI, 0.17-0.47]). Anisocoria in ambient light showed a similar but weaker association. CONCLUSION: Anisocoria correlates with injury severity and with patient outcomes after blunt TBI. Anisocoria after light stimulation seems to be a stronger predictor than does anisocoria in ambient light. These findings represent continued efforts to understand pupillary changes in the setting of TBI.
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http://dx.doi.org/10.1097/JNN.0000000000000613DOI Listing
December 2021

Quantitative pupillometry in patients with traumatic brain injury and loss of consciousness: A prospective pilot study.

J Clin Neurosci 2021 Sep 2;91:88-92. Epub 2021 Jul 2.

UT Southwestern Medical Center, Department of Neurological Surgery, USA. Electronic address:

Objective: Loss of consciousness (LOC) is a hallmark feature in Traumatic Brain Injury (TBI), and a strong predictor of outcomes after TBI. The aim of this study was to describe associations between quantitative infrared pupillometry values and LOC, intracranial hypertension, and functional outcomes in patients with TBI.

Methods: We conducted a prospective study of patients evaluated at a Level 1 trauma center between November 2019 and February 2020. Pupillometry values including the Neurological Pupil Index (NPi), constriction velocity (CV), and dilation velocity (DV) were obtained.

Results: Thirty-six consecutive TBI patients were enrolled. The median (range) age was 48 (range 21-86) years. The mean Glasgow Coma Scale score on arrival was 11.8 (SD = 4.0). DV trichotomized as low (<0.5 mm/s), moderate (0.5-1.0 mm/s), or high (>1.0 mm/s) was significantly associated with LOC (P = .02), and the need for emergent intervention (P < .01). No significant association was observed between LOC and NPi (P = .16); nor between LOC and CV (P = .07).

Conclusions: Our data suggests that DV, as a discrete variable, is associated with LOC in TBI. Further investigation of the relationship between discrete pupillometric variables and NPi may be valuable to understand the clinical significance of the pupillary light reflex findings in acute TBI.
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http://dx.doi.org/10.1016/j.jocn.2021.06.044DOI Listing
September 2021

Supratentorial intracerebral hemorrhage volume and other CT variables predict the neurological pupil index.

Clin Neurol Neurosurg 2021 01 5;200:106410. Epub 2020 Dec 5.

Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States; Department of Neurological Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, United States. Electronic address:

Objectives: There is growing interest in the ability of automated infrared pupillometry to assess severity of neurological illness. We studied the correlation between computed tomography (CT) indicators of intracerebral hemorrhage (ICH) severity with objective measures of the pupillary light reflex (PLR), and hypothesized that hemorrhage volume would predict the Neurological Pupil index™ (NPi™), an indicator of pupillary reactivity.

Methods: This study examined data from patients with supratentorial ICH who underwent serial pupillometer evaluations. CT images were examined to determine the location and laterality of the hemorrhage, along with hematoma volume (using the simplified ABC/2 method), midline shift, hydrocephalus score, and modified Graeb score (indicating interventricular hemorrhage). Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher's Exact X2, and multivariate modeling with constructed MAX-R models.

Results: Data were gathered from 44 subjects. ICH volume exhibited the strongest correlation with NPi (ipsilateral [r = 0.48, p < 0.0001, contralateral [(r = 0.39, p < 0.0001]). Horizontal midline shift of the septum pellucidum also correlated with NPi (ipsilateral [r = 0.25, p = 0.0006], contralateral [r = 0.15, p = 0.0106]), as did shift of the pineal gland (ipsilateral [r = 0.21, p = 0.0017], contralateral[r = 0.11, p = 0.0328]). ICH volume was the most predictive of abnormal NPi (AUC = 0.85 for ipsilateral and 0.88 for contralateral NPi), and multivariate modeling identified additional independent predictors of NPi.

Conclusion: ICH volume and shift of midline structures correlate with NPi, and abnormalities in NPi can be predicted by hematoma volume and other CT indicators of ICH severity. Future studies should explore the role of NPi in detecting early hematoma expansion and worsening midline shift.
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http://dx.doi.org/10.1016/j.clineuro.2020.106410DOI Listing
January 2021

Methods for Cleaning and Managing a Nurse-Led Registry.

J Neurosci Nurs 2020 Dec;52(6):328-332

Background: Clinical registries provide insight on the quality of patient care by providing data to identify associations and patterns in diagnosis, disease, and treatment. This has led to a push toward using large data sets in healthcare research. Nurse researchers are developing data registries, but most are unaware of how to manage a data registry. This article examines a neuroscience nursing registry to describe a quality control and data management process.

Data Quality Process: Our registry contains more than 90 000 rows of data from almost 5000 patients at 4 US hospitals. Data management is a continuous process that consists of 5 phases: screening, data organization, diagnostic, treatment, and missing data. These phases are repeated with each registry update.

Discussion: The interdisciplinary approach to data management resulted in high-quality data, which was confirmed by missing data analysis. Most technical errors could be systematically diagnosed and resolved using basic statistical outputs, and fixed in the source file.

Conclusion: The methods described provide a structured way for nurses and their collaborators to clean and manage registries.
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http://dx.doi.org/10.1097/JNN.0000000000000542DOI Listing
December 2020

Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury.

World Neurosurg 2021 01 2;145:e163-e169. Epub 2020 Oct 2.

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA. Electronic address:

Objective: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes.

Methods: We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied.

Results: Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n = 4) or ICP monitor placement (n = 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention.

Conclusions: AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.
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http://dx.doi.org/10.1016/j.wneu.2020.09.152DOI Listing
January 2021

Elevated blood pressure after craniotomy: A prospective observational study.

J Crit Care 2020 12 21;60:235-240. Epub 2020 Aug 21.

Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA.

Purpose: Close hemodynamic monitoring after craniotomy is routine given risk for post-operative hypertension, systemic and neurological complications. Patient and peri-operative variables associated with increased risk of post-craniotomy hypertension and complications are not well understood. Our analysis aims to estimate the incidence and prevalence of post-craniotomy hypertension, its time course, contributing factors, and post-craniotomy complications.

Material And Methods: This is a prospective study of patients admitted to the Neurosurgical Intensive Care Unit after an elective craniotomy. Variables associated with pre-surgical risk, demographics, and post-operative care were analyzed.

Results: A total of 282 patients were included in the final analysis, 44% had pre-existing hypertension. Post-craniotomy hypertension was seen in 21%, with a higher incidence in patients with pre-existing hypertension (p < .001), smaller craniotomies (p = .0035), and increased use of analgesic medications (p < .001). History of hypertension was the only independent risk factor for post-craniotomy hypertension in a multivariate regression model. Patients who developed post-craniotomy hypertension, showed a significant increase in length of stay, number and duration of antihypertensive treatment. However, post-craniotomy hypertension was not associated with a higher incidence of other post-operative complications.

Conclusions: Development of hypertension after craniotomy is multi-factorial. In this prospective study, a prior history of hypertension was the only associated independent risk factor.
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http://dx.doi.org/10.1016/j.jcrc.2020.08.013DOI Listing
December 2020

Early automated infrared pupillometry is superior to auditory brainstem response in predicting neurological outcome after cardiac arrest.

Resuscitation 2020 09 9;154:77-84. Epub 2020 Jun 9.

Department of Emergency and Critical Care Medicine, Nippon Medical School, Sendagi 1-1-5, Bunkyo-Ku, Tokyo, Japan.

Aim: Assessment of brainstem function plays a key role in predicting the neurological outcome after cardiac arrest. However, the relationship of the two quantitative brainstem assessment methods-automated infrared pupillometry (AIP) and auditory brainstem response (ABR)-with neurological prognoses remains unclear. This study compares the prognostic value of AIP and ABR after cardiopulmonary arrest.

Methods: This retrospective observational study included 124 comatose patients after cardiopulmonary arrest. ABR and AIP measurements were performed simultaneously within 72 h after return of spontaneous circulation. Neurological outcome was assessed at discharge by estimating the cerebral performance category (CPC) score; favourable neurological outcome (CPC score, 1-2) or poor neurological outcome (CPC score, 3-5). The correlation of each AIP parameter and ABR I-V wave latency was tested using Pearson's product moment correlation coefficient, and the prognostic value was compared using the area under the receiver operating characteristics curve (AUC).

Results: Pupillary light reflex (PLR) was not detected in 69 patients, and ABR wave V was not detected in 47 patients. All these patients had poor neurological outcome. Among those whose PLR and ABR could be measured, each AIP parameter had a tendency to be correlated with ABR I-V wave latency. Pupil constriction velocity provided the greatest AUC (0.819), with 81% sensitivity and 77% specificity. ABR I-V wave latency provided extremely low AUC (0.560).

Conclusions: Although AIP and ABR were correlated, the AIP measures were superior in predicting the neurological outcome after cardiac arrest as compared with the ABR measures.
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http://dx.doi.org/10.1016/j.resuscitation.2020.06.002DOI Listing
September 2020

Investigation of Pupillary Changes After Carotid Endarterectomy and Carotid Stent Placement Using Automated Pupillometry.

J Stroke Cerebrovasc Dis 2020 May 25;29(5):104693. Epub 2020 Feb 25.

University of Texas Southwestern Medical Center, Department of Neurological Surgery and Neurology and Neurotherapeutics, Dallas, Texas. Electronic address:

Introduction: Horner's syndrome has been reported after carotid artery endarterectomy (CEA) and carotid artery stenting (CS). This study evaluates pupillary changes after these procedures using automated pupillometry.

Methods: Retrospective analysis from a prospective database of pupillometry readings. Cases (14 patients with CEA/CS) were matched to controls (14 patients without CEA/CS). t test models were constructed to examine pupillary light reflex measures for CEA, CS, and controls.

Results: The 28 subjects had a mean age of 70 years, 50% were male, and 96% were Caucasian. There was no significant difference in the mean pupil size, constriction velocity (CV), dilation velocity (DV) between the procedural side compared to the contralateral side. However, the mean DV in the left eye after a left sided procedure among CS patients (.67) was lower than mean DV in left eye among controls (.88; P < .0001) and patients undergoing CEA (1.03; P < .0001).

Discussion: CS may result in disruption of the carotid artery plexus and decreased sympathetic response thereby reducing DV in the ipsilateral pupil. In addition, decreased CV can also been seen.

Conclusion: The findings confirm and extend those of previous authors suggesting that pupillary changes may be seen after CS and automated handheld pupillometry may aid in the detection of Horner Syndrome.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104693DOI Listing
May 2020

Investigating the association between eye colour and the Neurological Pupil index.

Aust Crit Care 2020 09 20;33(5):436-440. Epub 2019 Nov 20.

Department of Neurology & Neurotherapeutics, University of Texas Southwestern, 5323 Harry Hines Blvd., CS5, MC 8855, Dallas, TX 75390, USA; Department of Neurological Surgery, University of Texas Southwestern, 5323 Harry Hines Blvd., CS5, MC 8855, Dallas, TX 75390, USA. Electronic address:

Introduction: Brown or dark brown eyes make it difficult to distinguish the contrast between a black pupil and the surrounding iris, which may result in clinical assessment errors. The pupillometer can be used to derive an indexed value, the Neurological Pupil index™ (NPi) for pupillary light reflex. However, there are limited data associating the NPi and iris colour. We examine the NPi and eye colour association.

Methods: Data were pooled from the Establishing Normative Data for Pupillometer Assessments in Neuroscience Intensive Care (END-PANIC) Registry. The analysis includes 14,168 observations collected from 865 patients with neurological conditions who were admitted to the intensive care unit. Summary statistics and statistical models were developed to examine the association using Statistical Analysis Software (SAS) summary procedure.

Results: The mean age of the cohort was 56 years (standard deviation = 17). Eye colour included dark brown (n = 339), blue (n = 234), brown (n = 173), green (n = 82), and other (n = 37). There was significant differences (p < 0.0001) between mean NPi values by eye colour [blue = 4.08 (0.92), brown = 3.34 (1.45), dark = 3.71 (1.33), green = 4.08 (0.67), other = 3.76 (1.25)]. However, a further random-effects mixed model after controlling for confounding variables revealed no significant difference in NPi values among different eye colour groups.

Conclusions: The pupillary light reflex, when assessed using the pupillometer, is not dependent on the eye colour. Practitioners are not required to consider eye colour as a confounder when they perform pupillary assessment for examining patients with neurological conditions.
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http://dx.doi.org/10.1016/j.aucc.2019.10.001DOI Listing
September 2020

Distributions and Reference Ranges for Automated Pupillometer Values in Neurocritical Care Patients.

J Neurosci Nurs 2019 Dec;51(6):335-340

Bethany L. Lussier, MD, is Assistant Professor, Department of Neurology & Neurotherapeutics, UT Southwestern, Dallas, TX. Sonja E. Stutzman, PhD, is Research Manager, Department of Neurology & Neurotherapeutics, UT Southwestern, Dallas, TX. Folefac Atem, PhD, is Assistant Professor, Department of Biostatistics & Data Sciences, University of Texas Health Science Center, Dallas, TX. Aardhra M. Venkatachalam, MPH, is Data Specialist, Department of Biostatistics & Data Sciences, University of Texas Health Science Center, Dallas, TX. Anjali C. Perera, BSN RN, is Staff Nurse, Department of Neurology & Neurotherapeutics, UT Southwestern, Dallas, TX. Arianna Barnes, BSN RN, is Staff Nurse, Intensive Care, Mission Hospital, Providence St. Joseph Health, Mission Viejo, CA. Venkatesh Aiyagari, MD, is Professor, Department of Neurological Surgery, UT Southwestern, Dallas, TX.

Background: Automated pupillometry is becoming widely accepted as an objective measure of pupillary function, especially in neurocritical care units. Normative reference values and thresholds to denote a significant change are necessary for integrating automated pupillometry into practice.

Objective: Providing point estimates of normal ranges for pupillometry data will help clinicians intuit meaning from these data that will drive clinical interventions.

Methods: This study used a planned descriptive analysis using data from a multicenter registry including automated pupillometry assessments in 2140 subjects from 3 US hospitals collected during a 3-year period.

Results: We provide a comprehensive list of admission pupillometry data. Our data demonstrate significant differences in pupillary values for Neurological Pupil Index, latency, and constriction velocity when stratified by age, sex, or severity of illness defined by the Glasgow Coma Scale score.

Conclusion: This study provides a greater understanding of expected distributions for automated pupillometry values in a wide range of neurocritical care populations.
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http://dx.doi.org/10.1097/JNN.0000000000000478DOI Listing
December 2019

Development and Testing of an Electronic Multidisciplinary Rounding Tool.

AACN Adv Crit Care 2019 ;30(3):222-229

Elizabeth P. Gunter is Clinical Nurse Educator, Neuroscience, University of Texas Southwestern Medical Center, Dallas, Texas. Meera Viswanathan is Physician Assistant, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas. Sonja E. Stutzman is Clinical Research Manager, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas. DaiWai M. Olson is Professor, Neurological Surgery & Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas. Venkatesh Aiyagari is Professor, Neurological Surgery & Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5151 Harry Hines Blvd, Dallas, TX 75390

Patients hospitalized with neurologic and medical issues in the neuroscience critical care unit have widely varying and complex disease states that can change rapidly. The large amount of data that must be reviewed regularly by medical staff members presents a challenge to the provision of high-quality care to these patients. In an effort to lessen the burden, the authors' team implemented an electronic multidisciplinary rounding tool, which facilitates team communication by allowing accurate and concise review of patient information. The rounding tool is part of an ongoing quality improvement project and has been in use for 4 years. Nurses have reported that the tool provides a comprehensive summary of the patient's hospital stay that facilitates handoff during shift changes. A survey of nursing staff members demonstrated high levels of satisfaction with the tool during both multidisciplinary rounds and handoffs.
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http://dx.doi.org/10.4037/aacnacc2019815DOI Listing
February 2020

Automated Pupillometry in Neurocritical Care: Research and Practice.

Curr Neurol Neurosci Rep 2019 08 23;19(10):71. Epub 2019 Aug 23.

University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.

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. 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.
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http://dx.doi.org/10.1007/s11910-019-0994-zDOI Listing
August 2019

Pupillary Light Reflex Variability as a Predictor of Clinical Outcomes in Subarachnoid Hemorrhage.

J Neurosci Nurs 2019 Aug;51(4):171-175

Correspondence concerning this article should be addressed to Stefany Ortega-Perez, MSc RN, at She is an Assistant Professor, Universidad del Norte, Barranquilla, Colombia. Ifeoluwa Shoyombo, BS, is Graduate Medical Student, School of Medicine, University of Texas Southwestern, Dallas, TX. Venkatesh Aiyagari, MD, is Professor, University of Texas Southwestern, Dallas, TX. Folefac Atem, PhD MS, is Assistant Professor, University of Texas Southwestern, and is Director, Neurocritical Care Unit, Dallas, TX. Michelle Hill, MS RN AGCNS-BC CNRN CCRN SCRN, is Comprehensive Stroke Program Coordinator, Riverside Methodist Hospital, Columbus, OH. Sonja E. Stutzman, PhD, is Clinical Research Manager of Neuroscience Nursing Research Center, University of Texas Southwestern, Dallas, TX. DaiWai M. Olson, PhD RN CCRN FNCS, is Professor, University of Texas Southwestern, Dallas, TX.

Background: A change in the pupillary light reflex (PLR) is a sensitive indicator for detecting expanding intracranial lesions. Changes in PLR may be a prognostic marker for patients with intracranial lesions. The purpose of this analysis was to explore how PLR readings, size, constriction velocity (CV), dilation velocity (DV), Neurologic Pupil Index (NPi), and latency predict clinical outcome in patients with subarachnoid hemorrhage.

Methods: This is a secondary analysis of prospectively collected multicenter registry data. The within-subject standard deviation (WSD) of PLR values, NPi, size, CV, DV, and latency were explored as predictors of discharge modified Rankin Scale (mRS) in patients with subarachnoid hemorrhagic.

Results: Among 4403 pupillary readings from 82 patients with a diagnosis of subarachnoid hemorrhage, with a mean age of 57.7 years, the admission Glasgow Coma Scale median score was 14 (eye, 4; verbal, 4; motor, 6), and the mRS median was 0 on admission and 4 at discharge. Correlation between standard deviation of PLR values and discharge mRS was moderate and negative (r = -0.3 to -0.47, P < .01). The standard deviations for NPi, size, CV, and DV were significant for predicting discharge mRS (r = 0.23-0.28, P < .05) after controlling for admission Glasgow Coma Scale.

Conclusion: Patients with higher WSD PLR values showed better outcomes (ie, lower mRS at discharge), suggesting that patients with narrower WSD PLR are at a higher risk for poor outcomes.
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August 2019

An update on neurocritical care for intracerebral hemorrhage.

Expert Rev Neurother 2019 06 21;19(6):557-578. Epub 2019 May 21.

a Neurological Surgery & Neurology and Neurotherapeutics , The University of Texas Southwestern Medical Center , Dallas , TX , USA.

Intracerebral hemorrhage remains one of the leading causes of death and disability worldwide with few established interventions that improve neurologic outcome. Research dedicated to better understanding and treating hemorrhagic strokes has multiplied in the past decade. This review aims to discuss the current landscape of management of intracerebral hemorrhage in a critical care setting and provide updates regarding developments in therapeutic interventions and targets. PubMed was utilized to review recent literature, with a focus on large trials and meta-analyses, which have shaped current practice. Published committee guidelines were also included. A focus was placed on research published after 2015 in an effort to supplement previous reviews included in this publication. Literature pertaining to ICH management has allowed for a greater understanding of ineffective strategies as opposed to those of benefit. Despite this, mortality has improved worldwide, which may be the result of growing research efforts. Areas of future research that will impact mortality and improve neurologic outcomes include prevention of hematoma expansion, optimization of blood pressure targets, effective coagulopathy reversal, and minimally invasive surgical techniques to reduce hematoma burden.
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http://dx.doi.org/10.1080/14737175.2019.1618709DOI Listing
June 2019

Correlation of Objective Pupillometry to Midline Shift in Acute Stroke Patients.

J Stroke Cerebrovasc Dis 2019 Jul 25;28(7):1902-1910. Epub 2019 Apr 25.

Division of Neurocritical Care, Department of Neurology & Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas; Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas.

Background: Pupillary dysfunction is recognized as a sign of acute neurological deterioration due to worsening mass effect in patients with hemispheric strokes. Recent neuroimaging studies suggest that horizontal displacement of brain structures may be more important than vertical displacement in explaining these pupillary findings. Pupillometers allow objective and standardized evaluation of the pupillary light reflex. We hypothesized that pupillary data (Neurological Pupil index [NPi] and constriction velocity [CV]) obtained with a hand-held pupilometer, correlate with horizontal intracranial midline shift in patients with ischemic and hemorrhagic strokes.

Methods: The ENDPANIC registry is a prospective database of pupillometer readings in neurological patients. There were 134 patients in the database with an acute ischemic stroke or intracerebral hemorrhage who had at least 2 neurologic imaging studies (CT or MRI) and pupillometer assessments performed within 6 hours of the imaging. Horizontal shift of the septum pellucidum (SPS) was measured in 293 images. We computed the correlation between SPS and the following pupillary variables: size, NPi, CV (left, right, and left-right difference), followed by a regression model to control for confounders.

Results: There were 94 patients (70.1%) with an ischemic stroke and 40 patients (29.9%) had an intracerebral hemorrhage. After controlling for age, race, and gender, there was a significant correlation between the SPS and NPi (left [P < .001], right [P < .001]), CV (left [P < .005], right [P < .001]) pupillary asymmetry (absolute difference between right and left; P < .05), but not between SPS and pupillary size (left or right). There was a significant correlation between the NPi and CV for the right pupil when there was a right-to-left SPS (P < .001 and P < .05, respectively), but none between the NPi and CV for the left pupil and left-to-right SPS.

Conclusions: In patients with ischemic and hemorrhagic strokes, there is a significant correlation between SPS and the NPi, CV and pupillary asymmetry, but not with pupillary size.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.03.055DOI Listing
July 2019

A Decision Algorithm Is Not Superior to Clinician Judgment to Determine Need for Peripheral vs Central Venous Catheterization.

J Neurosci Nurs 2019 Jun;51(3):129-133

Questions or comments about this article may be directed to Venkatesh Aiyagari, MD, at He is a Professor of Neurological Surgery and Neurology and Neurotherapeutics at the University of Texas Southwestern Medical Center, Dallas, TX. Melissa Panter, BSN RN, is Registered Nurse, Neurointensive Care Unit, University of Texas Southwestern Medical Center, Dallas, TX. DaiWai M. Olson, PhD RN, is Professor, Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX. Sonja E. Stutzman, PhD, is Manager of Clinical Research, Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX.

Background: Venous access, via a midline peripheral catheter (midline) or a peripherally inserted central catheter, is used regularly in the neurointensive care unit as a means for prolonged infusion of drugs or medications. There is little research on how to choose the appropriate access device to use in this setting. The aim of this study is to trial an algorithm to assist clinicians in determining which device to use, as a way to reduce patient complications such as central line-associated bloodstream infection and deep vein thrombosis.

Methods: This quality improvement initiative included both retrospective and prospective data. A retrospective chart review was performed, and data were analyzed for variables associated with decision making between the 2 access devices. An algorithm was developed to assist clinicians with deciding between midline access and peripherally inserted central catheter access.

Results: A total of 325 charts were reviewed (126 retrospective and 109 prospective). Results show no significant differences in the demographic characteristics of either group. Before intervention, clinicians chose the correct access device 86% of the time, whereas after the intervention, clinicians chose the correct device 78% of the time (P = .06).

Conclusion: The results of this study indicate that the quality improvement intervention and algorithm decision-making tool did not improve accuracy of use of access devices.
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http://dx.doi.org/10.1097/JNN.0000000000000439DOI Listing
June 2019

Detection of delayed cerebral ischemia using objective pupillometry in patients with aneurysmal subarachnoid hemorrhage.

J Neurosurg 2019 01;132(1):27-32

Departments of1Neurological Surgery.

Objective: Cerebral vasospasm causing delayed cerebral ischemia (DCI) is a source of significant morbidity after subarachnoid hemorrhage (SAH). Transcranial Doppler is used at most institutions to detect sonographic vasospasm but has poor positive predictive value for DCI. Automated assessment of the pupillary light reflex has been increasingly used as a reliable way of assessing pupillary reactivity, and the Neurological Pupil Index (NPi) has been shown to decrease hours prior to the clinical manifestation of ischemic injury or herniation syndromes. The aim of this study was to investigate the role of automated pupillometry in the setting of SAH, as a potential adjunct to TCD.

Methods: Our analysis included patients that had been diagnosed with aneurysmal SAH and admitted to the neuro-intensive care unit of the University of Texas Southwestern Medical Center between November 2015 and June 2017. A dynamic infrared pupillometer was used for all pupillary measurements. An NPi value ranging from 3 to 5 was considered normal, and from 0 to 2.9 abnormal. Sonographic vasospasm was defined as middle cerebral artery velocities greater than 100 cm/sec with a Lindegaard ratio greater than 3 on either side on transcranial Doppler. Most patients had multiple NPi readings daily and we retained the lowest value for our analysis. We aimed to study the association between DCI and sonographic vasospasm, and DCI and NPi readings.

Results: A total of 56 patients were included in the final analysis with 635 paired observations of daily TCD and NPi data. There was no statistically significant association between the NPi value and the presence of sonographic vasospasm. There was a significant association between DCI and sonographic vasospasm, χ2(1) = 6.4112, p = 0.0113, OR 1.6419 (95% CI 1.1163-2.4150), and between DCI and an abnormal decrease in NPi, χ2(1) = 38.4456, p < 0.001, OR 3.3930 (95% CI 2.2789-5.0517). Twelve patients experienced DCI, with 7 showing a decrease of their NPi to an abnormal range. This change occurred > 8 hours prior to the clinical decline 71.4% of the time. The NPi normalized in all patients after treatment of their vasospasm.

Conclusions: Isolated sonographic vasospasm does not seem to correlate with NPi changes, as the latter likely reflects an ischemic neurological injury. NPi changes are strongly associated with the advent of DCI and could be an early herald of clinical deterioration.
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http://dx.doi.org/10.3171/2018.9.JNS181928DOI Listing
January 2019

Differentiate the Source and Site of Intracranial Pressure Measurements Using More Precise Nomenclature.

Neurocrit Care 2019 04;30(2):239-243

UT Southwestern Medical Center, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX, 75390-8897, USA.

Background: Intracranial pressure (ICP) monitoring is fundamental for neurocritical care patient management. For many years, ventricular and parenchymal devices have been available for this aim. The purpose of this paper is to review the published literature comparing ICP recordings via an intraventricular catheter or an intraparenchymal (brain tissue) catheter.

Methods: Literature search of Medline, CINAHL, Embase, and Scopus was performed in which manuscripts discussed both ICP monitoring via an intraventricular catheter and ICP monitoring through intraparenchymal (brain tissue) catheter. Keywords and MeSH terms used include critical care, intracranial pressure, ICP, monitoring, epidural catheter, intracranial hypertension, ventriculostomy, ventricular drain, external ventricular drain, and physiologic monitoring.

Results: Eleven articles met inclusion criteria. The published literature shows differences in simultaneously recorded ICP between the intraventricular and intraparenchymal sites.

Conclusions: We propose two new terms that more accurately identify the anatomical site of recording for the referenced ICP: intracranial pressure ventricular (ICP-v) and intracranial pressure brain tissue (ICP-bt). Further delineation of the conventional term "ICP" into these two new terms will clarify the difference between ICP-v and ICP-bt and their respective measurement locations.
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http://dx.doi.org/10.1007/s12028-018-0613-xDOI Listing
April 2019

Understanding the Relationship Between the Neurologic Pupil Index and Constriction Velocity Values.

Sci Rep 2018 05 3;8(1):6992. Epub 2018 May 3.

Department of Neurology & Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA.

The pupillary light reflex (PLR) describes the response when light hits the retina and sends a signal (cranial nerve II) to the Edinger-Westphal Nucleus which via cranial nerve III results in pupillary constriction. The Neurological Pupil index (NPi) and pupil constriction velocity (CV) are two distinct variables that can be observed and measured using a pupillometer. We examine NPi and CV in 27,462 pupil readings (1,617 subjects). NPi values <3.0 and a CV < 0.8 mm/sec were considered abnormal. Regression was used to clarify the effect of pupil size and repeated measures. An odds ratio of abnormal CV given normal NPi (and vice versa) was computed using the glimmixed (SAS) regression. Of 27,462 readings, 49.2% revealed bilaterally normal NPi wtih brisk CV, and 10.8% revealed bilaterally abnormal NPi and slow CV; 9.1% with unilaterally normal NPi and brisk CV where the opposite pupil had an abnormal NPi and slow CV. The remaining 30.9% revealed that one or both PLR had either a normal NPi with slow CV, or abnormal NPi with brisk CV. Brisk CV does not rule out an abnormal PLR; slow CV does not rule in abnormal PLR. Practitioners should consider these implications when interpreting pupillometry readings.
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http://dx.doi.org/10.1038/s41598-018-25477-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5934377PMC
May 2018

Correlation of Noninvasive Blood Pressure and Invasive Intra-arterial Blood Pressure in Patients Treated with Vasoactive Medications in a Neurocritical Care Unit.

Neurocrit Care 2018 06;28(3):265-272

Division of Neurocritical Care, Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Blvd. CS05102A, Dallas, TX, 75360, USA.

Background: The correlation between noninvasive (oscillometric) blood pressure (NBP) and intra-arterial blood pressure (IAP) in critically ill patients receiving vasoactive medications in a Neurocritical Care Unit has not been systematically studied. The purpose of this study is to examine the relationship between simultaneously measured NBP and IAP recordings in these patients.

Methods: Prospective observational study of patients (N = 70) admitted to a neurocritical care unit receiving continuous vasopressor or antihypertensive infusions. Paired NBP/IAP observations along with covariate and demographic data were abstracted via chart audit. Analysis was performed using SAS v9.4.

Results: A total of 2177 paired NBP/IAP observations from 70 subjects (49% male, 63% white, mean age 59 years) receiving vasopressors (n = 21) or antihypertensive agents (n = 49) were collected. Paired t test analysis showed significant differences between NBP versus IAP readings: ([systolic blood pressure (SBP): mean = 136 vs. 140 mmHg; p < 0.0001], [diastolic blood pressure (DBP): mean = 70 vs. 68 mmHg, p < 0.0001], [mean arterial blood pressure (MAP): mean = 86 vs. 90 mmHg, p < 0.0001]). Bland-Altman plots for MAP, SBP, and DBP demonstrate good inter-method agreement between paired measures (excluding outliers) and demonstrate NBP-IAP SBP differences at extremes of blood pressures. Pearson correlation coefficients show strong positive correlations for paired MAP (r = 0.82), SBP (r = 0.84), and DBP (r = 0.73) recordings. An absolute NBP-IAP SBP difference of > 20 mmHg was seen in ~ 20% of observations of nicardipine, ~ 25% of observations of norepinephrine, and ~ 35% of observations of phenylephrine. For MAP, the corresponding numbers were ~ 10, 15, and 25% for nicardipine, norepinephrine, and phenylephrine, respectively.

Conclusion: Despite overall strong positive correlations between paired NBP and IAP readings of MAP and SBP, clinically relevant differences in blood pressure are frequent. When treating with vasoactive infusions targeted to a specific BP goal, it is important to keep in mind that NBP and IAP values are not interchangeable.
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http://dx.doi.org/10.1007/s12028-018-0521-0DOI Listing
June 2018
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