Fixed Dilated Pupils in Severe Traumatic Brain Injury: Revisiting Prognostic Certainty Through Cases of Functional Recovery
Diana Marzouk1, Jayant Totlani1, William Mualem2, Ehsaun Heydari2, Andrew Caras2, Kelsey Atkinson2, Zachary Rollins3, Kathleen Nealon3, Joseph Bell IV2, Brian Cameron2, John Greer2, Fazila Aseem1
1Department of Neurology, 2Department of Neurosurgery, 3Department of General Surgery, Virginia Commonwealth University
Objective:
To demonstrate that fixed dilated pupils (FDP) may overestimate mortality and unfavorable outcomes in acute phases of traumatic brain injury (TBI).
Background:
Prognostic models, such as CRASH and IMPACT, heavily rely on Glasgow Coma Scale (GCS), pupil reactivity and CT features, which can be confounded by sedation, elevated intracranial pressure (ICP) and/or reversible ischemia. Overreliance on these prognostic markers prompts premature withdrawal of life-sustaining therapy. We present a case series of severe TBI with periods of FDP who achieved functional recovery despite poor predicted outcomes.
Design/Methods:
Case series with literature review.
Results:
Case#1: An 18-year-old man presented after fall with frontotemporal contusion with mass effect on CT, complicated by herniation with GCS 3 and FDP. Predicted prognosis: ~40% 14-day mortality and ~65% 6-month unfavorable outcome. After decompressive hemicraniectomy (DHC), ICP monitoring and optimal medical management, patient recovered to post-traumatic confusional state and Glasgow outcome Scale-Extended (GOS-E) 5 within 6-months.
Case#2: A 55-year-old man presented after fall with polytrauma with GCS 3 and FDP. CT head showed multifocal hemorrhage with cerebral edema. Predicted prognosis: ~75% 14-day mortality and ~90% 6-month unfavorable outcome. After DHC, ICP monitoring and optimal medical management, patient regained conscious wakefulness and GOS-E 6 within 6-months.
Case 3: An 86-year-old woman presented after fall with CT head notable for subdural hematoma (SDH), complicated by herniation with GCS 3 and notable FDP due to SDH expansion. Predicted prognosis: ~70% 14-day mortality and ~90% 6-month unfavorable outcome. After emergent craniotomy for SDH evacuation, patient regained conscious wakefulness with GOS-E 7 within 1-month.
Conclusions:
Severe TBI cases with transient FDP, high predicted mortality and unfavorable outcomes may survive to achieve meaningful recovery. FDP can reflect reversible ICP, ischemia or metabolic suppression rather than irreversible brainstem failure. Evidence-based neurocritical care and timely medical and surgical interventions can alter prognostic outcomes even in seemingly grim TBI cases.
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