Bilateral dilated unreactive pupils in paediatric patients following severe head injury - long-term outcome

ABSTRACT

Bilateral dilated fixed pupils in patients with severe traumatic brain injury are generally considered to represent a terminal event. They signify brainstem involvement or severe compression of the third cranial nerves. Since papillary functions are one of the criteria upon which further management decisions are based, bilateral unreactive pupils may lead to procrastination on the part of the surgeon. Authors present a retrospective analysis of a series of 30 paediatric patients aged up to 14 years with severe head injury [Glasgow coma score [GCS] 8 or less] and bilateral dilated unreactive pupils, who were admitted at the National Neurosurgical Centre, Oman between January 1996-December 2000. Patients with direct orbital trauma were excluded from the study. As per the protocol, the patients with severe head injury were aggressively managed at admission with elective ventilation and pharmacological paralysis. Our aim in this study was to analyse the outcome in this sub-group of patients with severe head injury with dilated fixed pupils despite adequate resuscitation and identify the prognostic factors that determine the ultimate outcome. Of the 30 patients, only 8 [26.6%] had a functional outcome and the remaining 22 [73.3%] a poor outcome, which included all six patients with polytrauma in shock at admission who later died despite resuscitation. Obliteration of basal cisterns [80% of cases] and focal brain contusion [46.6%] were the commonest computed tomography [CT] scan findings. Factors adversely affecting survival included shock, initial GCS of 3-4 and obliteration of the basal cisterns on CT scan. Most of the surviving patients on long-term follow-up revealed appreciable motor improvement but significant neurobehavioral and cognitive deficits