Corneal Reflex Testing in the Evaluation of a Comatose Patient: An Ode to Precise Semiology and Examination Skills

Maciel, Carolina B.; Youn, Teddy S.; Barden, Mary M.; Dhakar, Monica B.; Zhou, Sonya E.; Pontes-Neto, Octávio M.; Silva, Gisele Sampaio; Theriot, Jeremy; Greer, David M.

doi:10.1007/s12028-019-00896-0

Cited by 27 publications

(14 citation statements)

References 9 publications

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“…Clinical neurological examinations in the TTM-trial were performed according to local routines. We acknowledge that an increased focus on neurological examination techniques might have improved prognostic performance, since imprecise testing may be common [32]. Neuroimaging and SSEP was often performed on clinical indication in patients with presumed poor neurological prognosis likely leading to selection bias.…”

Section: Discussionmentioning

confidence: 99%

Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest

et al. 2020

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Purpose: To assess the performance of a 4-step algorithm for neurological prognostication after cardiac arrest recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). Methods: Retrospective descriptive analysis with data from the Target Temperature Management (TTM) Trial. Associations between predicted and actual neurological outcome were investigated for each step of the algorithm with results from clinical neurological examinations, neuroradiology (CT or MRI), neurophysiology (EEG and SSEP) and serum neuron-specific enolase. Patients examined with Glasgow Coma Scale Motor Score (GCS-M) on day 4 (72-96 h) post-arrest and available 6-month outcome were included. Poor outcome was defined as Cerebral Performance Category 3-5. Variations of the ERC/ESICM algorithm were explored within the same cohort. Results: The ERC/ESICM algorithm identified poor outcome patients with 38.7% sensitivity (95% CI 33.1-44.7) and 100% specificity (95% CI 98.8-100) in a cohort of 585 patients. An alternative cutoff for serum neuron-specific enolase, an alternative EEG-classification and variations of the GCS-M had minor effects on the sensitivity without causing false positive predictions. The highest overall sensitivity, 42.5% (95% CI 36.7-48.5), was achieved when prognosticating patients irrespective of GCS-M score, with 100% specificity (95% CI 98.8-100) remaining. Conclusion: The ERC/ESICM algorithm and all exploratory multimodal variations thereof investigated in this study predicted poor outcome without false positive predictions and with sensitivities 34.6-42.5%. Our results should be validated prospectively, preferably in patients where withdrawal of life-sustaining therapy is uncommon to exclude any confounding from self-fulfilling prophecies.

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Section: Discussionmentioning

confidence: 99%

Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest

et al. 2020

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“…The corneal reflex tests pontine function through cranial nerves V and VII, and is of particular prognostic importance owing to the anatomical proximity of its pathway to pontine arousal nuclei 41 ; however, prognostication using this reflex is also subject to vagaries in testing. A recent worldwide survey of intensivists and neurologists found that clinicians commonly test for a response too far laterally on the sclera and use submaximal stimulation, both of which could lead to a falsely negative (absent) reflex response 87 . Corneal sensitivity is highest at the edge of the iris and decreases further out on the conjunctiva 88 .…”

Section: Acute Disorders Of Consciousnessmentioning

confidence: 99%

Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies

et al. 2020

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“…Variations in assessment techniques of corneal reflex have been documented, as well. A recent survey [127] of 959 respondents raised concerns about the technique used to elicit the corneal reflex: 148 (26%) physicians reported applying the stimulus on the temporal conjunctiva rather than on the cornea.…”

Section: Clinical Examination Ocular Reflexesmentioning

confidence: 99%

Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review

et al. 2020

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Purpose: To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3-5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods: PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013-April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results: Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2-5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion: In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169

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Corneal Reflex Testing in the Evaluation of a Comatose Patient: An Ode to Precise Semiology and Examination Skills

Cited by 27 publications

References 9 publications

Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest

Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest

Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies

Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review

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