Screening for Intracranial Hypertension Using Lighting-Invariant Computational Pupillometry: A Single-Center Pilot Study

Abstract Background Invasive intracranial pressure (ICP) monitoring is the reference standard for detecting intracranial hypertension but requires neurosurgical expertise and carries procedural risks. Non-invasive methods with high negative predictive value (NPV) could serve as screening tools to rule out dangerous ICP elevations and guide decisions about invasive monitoring. We conducted a pilot evaluation to assess whether a smartphone-based, lighting-invariant quantitative pupillometry platform achieves the high NPV needed for clinical screening. Methods This prospective single-center pilot study in neuro-ICU enrolled adults with acute neurological emergencies who underwent serial bilateral pupillometry alongside clinically indicated intraparenchymal ICP monitoring. The primary outcome was diagnostic performance of the Pupil Reactivity (PuRe) Score for identifying intracranial hypertension (ICP ≥ 20 mmHg), with emphasis on NPV. Secondary analyses examined PuRe Score correlations with ICP, clinical phenotypes across reactivity strata, ambient lighting invariance, and subgroup performance by Glasgow Coma Scale (GCS). Results Nineteen patients contributed 731 pupillometry recordings, of which 634 (87%) had concurrent invasive ICP measurements; 112 recordings (18%) showed elevated ICP. PuRe Score exhibited a significant inverse correlation with ICP (Spearman ρ =− 0.17, p