Abstract Details

Title Fixed Dilated Pupils in Severe Traumatic Brain Injury: Revisiting Prognostic Certainty Through Cases of Functional Recovery

Topic Neuro Trauma and Critical Care

Presentation(s) P1 - Poster Session 1 (8:00 AM-9:00 AM)

Poster/Presentation
Number 18-003

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.

Authors/Disclosures
Diana Marzouk, DO (VCUHS) PRESENTER	Dr. Marzouk has nothing to disclose.
Jayant Totlani	Jayant Totlani has nothing to disclose.
William Mualem, MD	Dr. Mualem has nothing to disclose.
Ehsaun Heydari, MD	Dr. Heydari has nothing to disclose.
Andrew Caras, MD	Dr. Caras has nothing to disclose.
Kelsey A. Atkinson, MD	Dr. Atkinson has nothing to disclose.
Zachary Rollins, MD	Dr. Rollins has nothing to disclose.
Kathleen Nealon, MD	Dr. Nealon has nothing to disclose.
Joseph Bell IV, MD, PhD	Dr. Bell has nothing to disclose.
Judy L. Cameron, PhD	Dr. Cameron has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Child Mind Institute. Dr. Cameron has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for National Scientific Council on the Developing Child.
John E. Greer	Dr. Greer has nothing to disclose.
Fazila Aseem, MD, MPH	Dr. Aseem has nothing to disclose.

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