Quantitative Pupillometry for Intracranial Pressure (ICP) Monitoring in Traumatic Brain Injury: A Scoping Review.

The neurological examination has remained key for the detection of worsening in neurocritical care patients, particularly after traumatic brain injury (TBI). New-onset, unreactive anisocoria frequently occurs in such situations, triggering aggressive diagnostic and therapeutic measures to address life-threatening elevations in intracranial pressure (ICP). As such, the field needs objective, unbiased, portable, and reliable methods for quickly assessing such pupillary changes. In this area, quantitative pupillometry (QP) proves promising, leveraging the analysis of different pupillary variables to indirectly estimate ICP. Thus, this scoping review seeks to describe the existing evidence for the use of QP in estimating ICP in adult patients with TBI as compared with invasive methods, which are considered the standard practice. This review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, with a main search of PubMed and EMBASE. The search was limited to studies of adult patients with TBI published in any language between 2012 and 2022. Eight studies were included for analysis, with the vast majority being prospective studies conducted in high-income countries. Among QP variables, serial rather than isolated measurements of neurologic pupillary index, constriction velocity, and maximal constriction velocity demonstrated the best correlation with invasive ICP measurement values, particularly in predicting refractory intracranial hypertension. Neurologic pupillary index and ICP also showed an inverse relationship when trends were simultaneously compared. As such, QP, when used repetitively, seems to be a promising tool for noninvasive ICP monitoring in patients with TBI, especially when used in conjunction with other clinical and neuromonitoring data.

Non-Invasive Methods for Intracranial Pressure Monitoring in Traumatic Brain Injury Using Transcranial Doppler: A Scoping Review.

Intracranial pressure (ICP) monitoring is necessary for managing patients with traumatic brain injury (TBI). Although gold-standard methods include intraventricular or intraparenchymal transducers, these systems cannot be used in patients with coagulopathies or in those who are at high risk of catheter-related infections, nor can they be used in resource-constrained settings. Therefore, a non-invasive modality that is more widely available, cost effective, and safe would have tremendous impact. Among such non-invasive choices, transcranial Doppler (TCD) provides indirect ICP estimates through waveform analysis of cerebral hemodynamic changes. The objective of this scoping review is to describe the existing evidence for the use of TCD-derived methods in estimating ICP in adult TBI patients as compared with gold-standard invasive methods. This review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, with a main search of PubMed and Embase. The search was limited to studies conducted in adult TBI patients published in any language between 2012 and 2022. Twenty-two studies were included for analysis, with most being prospective studies conducted in high-income countries. TCD-derived non-invasive ICP (nICP) methods are either mathematical or non-mathematical, with the former having slightly better correlation with invasive methods, especially when using time-trending ICP dynamics over one-time estimated values. Nevertheless, mathematical methods are associated with greater cost and complexity in their application. Formula-based methods showed promise in excluding elevated ICP, exhibiting a high negative predictive value. Therefore, TCD-derived methods could be useful in assessing ICP changes instead of absolute ICP values for high-risk patients, especially in low-resource settings.

Using Optic Nerve Sheath Diameter for Intracranial Pressure (ICP) Monitoring in Traumatic Brain Injury: A Scoping Review.

INTRODUCTION: Neuromonitoring represents a cornerstone in the comprehensive management of patients with traumatic brain injury (TBI), allowing for early detection of complications such as increased intracranial pressure (ICP) [1]. This has led to a search for noninvasive modalities that are reliable and deployable at bedside. Among these, ultrasonographic optic nerve sheath diameter (ONSD) measurement is a strong contender, estimating ICP by quantifying the distension of the optic nerve at higher ICP values. Thus, this scoping review seeks to describe the existing evidence for the use of ONSD in estimating ICP in adult TBI patients as compared to gold-standard invasive methods. MATERIALS AND METHODS: This review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, with a main search of PubMed and EMBASE. The search was limited to studies of adult patients with TBI published in any language between 2012 and 2022. Sixteen studies were included for analysis, with all studies conducted in high-income countries. RESULTS: All of the studies reviewed measured ONSD using the same probe frequency. In most studies, the marker position for ONSD measurement was initially 3 mm behind the globe, retina, or papilla. A few studies utilized additional parameters such as the ONSD/ETD (eyeball transverse diameter) ratio or ODE (optic disc elevation), which also exhibit high sensitivity and reliability. CONCLUSION: Overall, ONSD exhibits great test accuracy and has a strong, almost linear correlation with invasive methods. Thus, ONSD should be considered one of the most effective noninvasive techniques for ICP estimation in TBI patients.

Gastric adenocarcinoma: A one-of-a-kind etiology of autoimmune paraneoplastic encephalitis.

INTRODUCTION AND IMPORTANCE: Paraneoplastic neurologic syndromes are a group of neurologic disorders that can affect any part of the nervous system and are mediated by immune pathogens produced by cancer. These disorders occur distant to a malignant tumor and are not caused by metastasis, nutritional disorders or side effects of therapy related to the tumor. CLINICAL FINDINGS: We present the case of a 47-year-old male patient who was admitted to the emergency department due to 1 month of neurological impairment including generalized tonic-clonic movements. He was admitted to the institution and was taken to multiple neurologic tests, all of which were normal, including a negative panel for onconeural antibodies. He persisted with seizures and was taken to a 24-hour video electroencephalogram which showed features consistent with moderate encephalopathy and focal epileptiform activity, which evolved into status epilepticus. Suspecting immune - mediated encephalitis, a therapeutic trial was started with methylprednisolone and plasma exchange, and a positron emission tomography was indicated. The positron emission tomography showed in the brain regions of marked hypometabolism and hypermetabolic thickening of gastric infiltrative aspect fundocorporal topography. Upper gastrointestinal endoscopy revealed in the subcardial region a mass-like lesion with an ulcer-infiltrative appearance, pathology showed an adenocarcinoma. CONCLUSION: Autoimmune encephalitis as a paraneoplastic neurological syndrome of a gastric adenocarcinoma have been documented in few patients in the literature. It is important to describe and recognize clinical findings in this cases to be able to suspect malignancy and thus have early diagnosis, start treatment promptly and avoid irreversible neurological sequelae.