Department of Neurology, Friedrich-Alexander-University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
J Neurol. 2023 Sep;270(9):4507-4517. doi: 10.1007/s00415-023-11797-w. Epub 2023 Jun 10.
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.
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).
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%).
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.
尽管血管内治疗（EVT）对大血管闭塞（LVO）缺血性卒中有益，但占位性脑水肿（BE）是一种有害的并发症。在重症监护环境中，需要 CT 成像来监测这些患者。然而，能够预测患者是否发生 BE 的床边技术将有助于实现高效的患者护理。我们评估了自动瞳孔测量术在 EVT 后患者随访中的临床意义。
从 2018 年 10 月至 2021 年 10 月，对接受前循环 LVO EVT 后的神经重症监护病房患者进行了回顾性入组。我们在 ICU 入住第 1-3 天内每小时监测瞳孔反应参数[光反射潜伏期（Lat）、收缩和扩张速度（CV、DV）、孔径变化百分比（per-change）；NeurOptics 瞳孔计]。BE 定义为 EVT 后 3-5 天随访成像时中线移位≥5mm。我们计算了个体间连续参数对之间的平均差异（mean-deltas），确定了 BE 发生的最佳判别截止值（ROC 分析），并评估了瞳孔测量术对 BE 发生的预后性能（敏感性/特异性/阳性/阴性预测值）。
共纳入 122 例患者[67 例女性，73 岁（61.0-85.0）]的 3241 次瞳孔评估。13/122 例患者发生 BE。与无 BE 患者相比，BE 患者的 CV、DV 和 per-changes 明显较低。在 EVT 后第 1 天，BE 患者的 CV、DV 和 per-changes 的 mean-deltas 明显低于无 BE 患者。计算的阈值对两组的阳性预测值相当低，但我们发现 CV、DV、per-changes 和 mean-deltas 的高阴性预测值（最高：98.4%）。
我们的数据表明，LVO-EVT 后早期瞳孔反应的非侵入性变化与 BE 之间存在关联。瞳孔测量术可以识别不太可能发生 BE 的患者，并且可能不需要重复的随访成像或抢救治疗。
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