Carolina B Maciel1,2,3, Teddy S Youn4, Mary M Barden5, Monica B Dhakar5,6, Sonya E Zhou5, Octavio M Pontes-Neto7, Gisele Sampaio Silva8, Jeremy J Theriot9, David M Greer5,10. 1. Department of Neurology, UF Health, Shands Hospital, McKnight Brain Institute, University of Florida College of Medicine, University of Florida, Room L3-185, 1149 Newell Drive, Gainesville, FL, 32611, USA. carolina.maciel@neurology.ufl.edu. 2. Department of Neurology, Yale University School of Medicine, New Haven, CT, USA. carolina.maciel@neurology.ufl.edu. 3. Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA. carolina.maciel@neurology.ufl.edu. 4. Department of Neurology, UF Health, Shands Hospital, McKnight Brain Institute, University of Florida College of Medicine, University of Florida, Room L3-185, 1149 Newell Drive, Gainesville, FL, 32611, USA. 5. Department of Neurology, Yale University School of Medicine, New Haven, CT, USA. 6. Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30303, USA. 7. Stroke Service, Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil. 8. Department of Neurology and Neurosurgery, Universidade Federal de São Paulo and Hospital Israelita Albert Einstein, São Paulo, SP, Brazil. 9. Department of Neurology, University of Utah, Salt Lake City, UT, 84108, USA. 10. Department of Neurology, Boston University School of Medicine, Boston, MA, 02118, USA.
Abstract
BACKGROUND/ OBJECTIVE: The corneal reflex assesses the integrity of the trigeminal and facial cranial nerves. This brainstem reflex is fundamental in neuroprognostication after cardiac arrest and in brain death determination. We sought to investigate corneal reflex testing methods among neurologists and general critical care providers in the context of neuroprognostication following cardiac arrest. METHODS: This is an international cross-sectional study disseminated to members of the Neurocritical Care Society, Society of Critical Care Medicine, and American Academy of Neurology. We utilized an open Web-based survey (Qualtrics®, Provo, UT, USA) to disseminate 26 questions regarding neuroprognostication practices following cardiac arrest, in which 3 questions pertained to corneal reflex testing. Descriptive statistical measures were used, and subgroup analyses performed between neurologists and non-neurologists. Questions were not mandatory; therefore, the percentages were relative to the number of respondents for each question. RESULTS: There were 959 respondents in total. Physicians comprised 85.1% of practitioners (762 out of 895), of which 55% (419) identified themselves as non-neurologists and 45% (343) as neurologists. Among physicians, 85.9% (608 out of 708) deemed corneal reflex relevant for prognostication following cardiac arrest (neurologists 84.4% versus non-neurologists 87.0%). A variety of techniques were employed for corneal reflex testing, the most common being "light cotton touch" (59.2%), followed by "cotton-tipped applicator with pressure" (23.9%), "saline or water squirt" (15.9%), and "puff of air" (1.0%). There were no significant differences in the methods for testing between neurologists and non-neurologists (p = 0.52). The location of stimulus application was variable, and 26.1% of physicians (148/567) apply the stimulus on the temporal conjunctiva rather than on the cornea itself. CONCLUSIONS: Corneal reflex testing remains a cornerstone of the coma exam and is commonly used in neuroprognostication of unconscious cardiac arrest survivors and in brain death determination. A wide variability of techniques is noted among practitioners, including some that may provide suboptimal stimulation of corneal nerve endings. Imprecise testing in this setting may lead to inaccuracies in critical settings, which carries significant consequences such as guiding decisions of care limitations, misdiagnosis of brain death, and loss of public trust.
BACKGROUND/ OBJECTIVE: The corneal reflex assesses the integrity of the trigeminal and facial cranial nerves. This brainstem reflex is fundamental in neuroprognostication after cardiac arrest and in brain death determination. We sought to investigate corneal reflex testing methods among neurologists and general critical care providers in the context of neuroprognostication following cardiac arrest. METHODS: This is an international cross-sectional study disseminated to members of the Neurocritical Care Society, Society of Critical Care Medicine, and American Academy of Neurology. We utilized an open Web-based survey (Qualtrics®, Provo, UT, USA) to disseminate 26 questions regarding neuroprognostication practices following cardiac arrest, in which 3 questions pertained to corneal reflex testing. Descriptive statistical measures were used, and subgroup analyses performed between neurologists and non-neurologists. Questions were not mandatory; therefore, the percentages were relative to the number of respondents for each question. RESULTS: There were 959 respondents in total. Physicians comprised 85.1% of practitioners (762 out of 895), of which 55% (419) identified themselves as non-neurologists and 45% (343) as neurologists. Among physicians, 85.9% (608 out of 708) deemed corneal reflex relevant for prognostication following cardiac arrest (neurologists 84.4% versus non-neurologists 87.0%). A variety of techniques were employed for corneal reflex testing, the most common being "light cotton touch" (59.2%), followed by "cotton-tipped applicator with pressure" (23.9%), "saline or water squirt" (15.9%), and "puff of air" (1.0%). There were no significant differences in the methods for testing between neurologists and non-neurologists (p = 0.52). The location of stimulus application was variable, and 26.1% of physicians (148/567) apply the stimulus on the temporal conjunctiva rather than on the cornea itself. CONCLUSIONS: Corneal reflex testing remains a cornerstone of the coma exam and is commonly used in neuroprognostication of unconscious cardiac arrest survivors and in brain death determination. A wide variability of techniques is noted among practitioners, including some that may provide suboptimal stimulation of corneal nerve endings. Imprecise testing in this setting may lead to inaccuracies in critical settings, which carries significant consequences such as guiding decisions of care limitations, misdiagnosis of brain death, and loss of public trust.
Authors: Claudio Sandroni; Sonia D'Arrigo; Sofia Cacciola; Cornelia W E Hoedemaekers; Marlijn J A Kamps; Mauro Oddo; Fabio S Taccone; Arianna Di Rocco; Frederick J A Meijer; Erik Westhall; Massimo Antonelli; Jasmeet Soar; Jerry P Nolan; Tobias Cronberg Journal: Intensive Care Med Date: 2020-09-11 Impact factor: 17.440
Authors: Marion Moseby-Knappe; Erik Westhall; Sofia Backman; Niklas Mattsson-Carlgren; Irina Dragancea; Anna Lybeck; Hans Friberg; Pascal Stammet; Gisela Lilja; Janneke Horn; Jesper Kjaergaard; Christian Rylander; Christian Hassager; Susann Ullén; Niklas Nielsen; Tobias Cronberg Journal: Intensive Care Med Date: 2020-06-03 Impact factor: 17.440
Authors: Sonya E Zhou; Mary M Barden; Emily J Gilmore; Octavio M Pontes-Neto; Gisele Sampaio Silva; Pedro Kurtz; Jamary Oliveira-Filho; Pedro Telles Cougo-Pinto; Fernando G Zampieri; Nicholas J Napoli; Jeremy J Theriot; David M Greer; Carolina B Maciel Journal: Crit Care Explor Date: 2021-01-11