PROGNOSTIC AND CLINICAL RELEVANCE OF PUPILLARY RESPONSES, INTRACRANIAL-PRESSURE MONITORING AND BRAIN-STEM AUDITORY-EVOKED POTENTIALS IN COMATOSE PATIENTS WITH ACUTE SUPRATENTORIAL MASS LESIONS

Objective: To test the hypothesis that the clinical condition and outc ome in patients with acute supratentorial mass lesions can be assessed by determination of pupillary abnormalities, measurement of intracran ial pressure, and results of brainstem auditory evoked potentials. Des ign: Prospective case series of 55 patients presenting with supratento rial mass lesions. Setting: Neurologic and neurosurgical intensive car e unit of a tertiary care center. Patients: Fifty-five comatose patien ts (26 female/29 male; 9 to 70 yrs of age [mean 44]). Interventions: P upillary abnormalities were rated ''normal'' ''unilaterally enlarged,' ' ''unilaterally fixed,'' and ''bilaterally abnormal.'' The outcome wa s rated using the Glasgow Outcome Scale. Intracranial pressure values were graded into five categories. Brainstem auditory evoked potentials were rated ''bilaterally normal,'' ''unilaterally abnormal'' or ''bil aterally abnormal'' according to normative data. Statistical evaluatio n was performed by frequency analysis (Fisher's exact test, two-tailed ) and calculation of contingency coefficients. Measurements and Main R esults: Outcome was poor in 24 patients, good in eight patients, and 2 3 patients were severely disabled. Statistical analysis showed prognos tic significance of both pupillary abnormalities (p =.0000542; conting ency coefficient =.589) and increased intracranial pressure (p =.0084; contingency coefficient =.352). Brainstem auditory evoked potential c ategories correlated significantly with pupillary abnormalities (p =.0 00276; contingency coefficient =.505) and increased intracranial press ure (p =.0301; contingency coefficient = .502) but did not predict out come (p =.645; contingency coefficient =.321). Conclusions: Pupillary abnormalities may serve as a reliable parameter, which may even be sup erior to brainstem auditory evoked potential testing and intracranial pressure monitoring for prediction of outcome in comatose individuals with supratentorial mass lesions. Brainstem auditory evoked potentials can be used to support the clinical relevance of abnormal pupillary s tatus and increased intracranial pressure but are of no prognostic val ue. Increased intracranial pressure is associated with abnormalities i n pupillary status and brainstem auditory evoked potentials. Examinati on for pupillary abnormalities in combination with intracranial pressu re monitoring and brainstem auditory evoked potential testing seems to be a useful strategy in managing patients with supratentorial mass le sions in critical care units.