Abstract Details

Title Unilateral Spontaneous Pupillary Activity in Brain Death: A Case Report

Topic Neuro Trauma and Critical Care

Presentation(s) P14 - Poster Session 14 (11:45 AM-12:45 PM)

Poster/Presentation
Number 1-003

Objective We present a case of unilateral spontaneous episodic pupillary activity in a patient with confirmed brain death.

Background Clinical findings in brain death include absent cerebral and brainstem function. Exam findings include a comatose patient with absence of brain-originated motor responses, brainstem reflexes and lack of spontaneous breathing demonstrated by apnea test. Pupils should be fixed at mid-position and dilated. We present a patient with unilateral spontaneous pupillary activity despite confirmed brain death, which has only been described twice before in the literature.

Design/Methods NA

Results A 66-year-old man with a history of alcohol abuse was admitted after being found unresponsive. He was intubated on presentation to the emergency department due to acute hypoxia. Computated tomography (CT) head showed a right hemispheric hemorrhage with intraventricular extension and a 1.3 cm midline shift. He underwent a right sided craniotomy with evacuation of hematoma. Over the next 48 hours, his neurological condition declined. Repeat CT imaging demonstrated worsening edema resulting in tonsillar herniation. Patient subsequently lost brainstem reflexes, motor responses, and spontaneous breaths. The left pupil was fixed, dilated and non-reactive. His right pupil however, displayed spontaneous, alternating episodes of dilation and constriction, occurring every 1 to 2 seconds, that was independent of respiratory patterns or external stimuli such as pain or light. A nuclear scan revealed a “hot nose” sign, confirming brain death.

Conclusions Our patient exhibited a rare phenomenon of unilateral spontaneous episodic pupillary dilation-constriction despite clinical and imaging confirmation of brain death. As this occurred without stimulus, we explored possible explanations on non-central origin. These may be due to cyclic stimulus from intermittent discharges of dying neurons through an intact efferent tract, or hypersensitivity of denervated sphincter muscle to remaining neurotransmitters. It is critical to recognize this phenomenon to avoid unnecessary delay in the diagnosis of brain death.

Authors/Disclosures
Atef Kokash, DO PRESENTER	Dr. Kokash has nothing to disclose.
Erafat Rehim, MD (LVHN)	Dr. Rehim has nothing to disclose.
Tsneem Mbydeen, MBBS (LVHN)	Dr. Mbydeen has nothing to disclose.
Preet M. Varade, MD (Lehigh Valley Hospital - Cedar Crest)	Dr. Varade has nothing to disclose.

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