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Automated Pupillometry for Assessment of Treatment Success in Nonconvulsive Status Epilepticus

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An Invited Commentary to this article was published on 30 July 2021

Abstract

Background

Altered pupillary function may reflect nonconvulsive status epilepticus (NCSE). Neurological pupil index (NPi) assessed by automated pupillometry is a surrogate marker of global pupillary function. We aimed to assess NPi changes in relation to NCSE treatment response.

Methods

In this prospective observational study, serial automated pupillometry was performed in 68 NCSE episodes. In accordance with local standards, patients were treated with clonazepam (1–2 mg), levetiracetam (40 mg/kg), and lacosamide (5 mg/kg) in a stepwise approach under continuous electroencephalography monitoring until NCSE was terminated. Patients with refractory NCSE received individualized regimens. NPi was assessed bilaterally before and after each treatment step. For statistical analysis, the lower NPi of both sides (minNPi) was used. Nonparametric testing for matched samples and Cohen’s d to estimate effect size were performed. Principal component analysis was applied to assess the contribution of baseline minNPi, age, sex, and NCSE duration to treatment outcome.

Results

In 97.1% of 68 episodes, NCSE could be terminated; in 16.2%, NCSE was refractory. In 85.3% of episodes, an abnormal baseline minNPi ≤ 4.0 was obtained. After NCSE termination, minNPi increased significantly (p < 0.001). Cohen’s d showed a strong effect size of 1.24 (95% confidence interval 0.88–1.61). Baseline minNPi was higher in clonazepam nonresponders vs. responders (p = 0.008), minNPi increased in responders (p < 0.001) but not in nonresponders. NCSE refractivity was associated with normal baseline minNPi (principal component analysis, component 1, 32.6% of variance, r = 0.78), male sex, and longer NCSE duration (component 2, 27.1% of variance, r = 0.62 and r = 0.78, respectively).

Conclusions

Automated pupillometry may be a helpful noninvasive neuromonitoring tool for the assessment of patients with NCSE and response to treatment.

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Funding

This study received no funding.

Author information

Authors and Affiliations

  1. Department of Neurology, Klinikum Kassel, Kassel, Germany

    Jana Godau, Kaushal Bharad, Johannes Rösche, Gabor Nagy & Julian Bösel

  2. Emergency Department, Klinikum Kassel, Kassel, Germany

    Jana Godau, Kaushal Bharad & Klaus Weber

  3. Department of Neurology, University of Rostock, Rostock, Germany

    Johannes Rösche

  4. Department of Neurosurgery, Klinikum Kassel, Kassel, Germany

    Gabor Nagy & Stefanie Kästner

Authors
  1. Jana Godau
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  2. Kaushal Bharad
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  3. Johannes Rösche
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  4. Gabor Nagy
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  5. Stefanie Kästner
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  6. Klaus Weber
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  7. Julian Bösel
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Contributions

JG is corresponding author and responsible for manuscript submission. JG and JB contributed to conceptualization, review, editing, figure and table creation. JR, KB, GN and SK contributed to review and editing of text, tables and figures. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Jana Godau.

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Conflicts of interest

JR reports personal fees from Eisai GmbH, outside the submitted work. JB reports personal fees from Medtronic, personal fees from Zoll, personal fees from Böhringer Ingelheim, grants from German Neurocritical Care Society (DGNI), grants from Patient-Centered Outcomes Research Institute (PCORI), outside the submitted work. All remaining authors have no conflicts to disclose.

Ethical approval/informed consent

The study was performed in adherence to ethical guidelines. Ethical approval including a formal consent waiver for observational pupillometry was granted by the Hesse Medical Association Ethical Board (FF 20/2018).

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This article is related to the Invited Commentary available at https://springer.longhoe.net/article/10.1007/s12028-021-01274-5

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Godau, J., Bharad, K., Rösche, J. et al. Automated Pupillometry for Assessment of Treatment Success in Nonconvulsive Status Epilepticus. Neurocrit Care 36, 148–156 (2022). https://doi.org/10.1007/s12028-021-01273-6

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  • DOI: https://doi.org/10.1007/s12028-021-01273-6

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