Fixed and dilated pupils after trauma, stroke, and previous intracranial surgery: management and outcome

Objectives-To clarify whether different causative events (trauma, stroke, i ntracranial surgery), time of intervention, and treatment mode influence ou tcome, patients with fixed and dilated pupils (FDPs) in a prospective neuro surgical series were evaluated. Methods-Ninety nine consecutive patients who presented with or developed on e or two FDPs, were split into three groups according to the respective aet iology: 46 patients had a trauma, 41 patients a stroke (subarachnoid or int racerebral haemorrhage), and 12 patients had undergone previous elective in tracranial surgery. Appropriate therapy was performed depending on the CT f indings. Outcome was classified according to the Glasgow outcome scale (GOS ). Results-Overall mortality was 75%. In 15% outcome was unfavourable (GOS 2 a nd 3), and in 10% favourable (GOS 4, 5) at 24 month follow up. No differenc es in outcome were found between trauma, stroke, and postelective surgery g roups. Unilaterally FDP was associated with a better chance of survival (46 % nu 13%; p <0.01). Age did not correlate with survival, but younger surviv ors had a significantly better outcome. Patients in whom an intracranial ma ss was removed surgically had a 42% survival rate, compared with 8% with co nservative treatment (p <0.01). Patients with a shorter delay from FDPs to intervention had a better chance of recovery after trauma and previous intr acranial surgery (p <0.05). No patient survived better than a vegetative st ate, if previous FDPs did not become reactive shortly after therapy. If bot h pupils became reactive on therapy, the chance of survival was 62%. Of the se survivors 42% had a favourable outcome. Conclusion-Bilateral restoration of pupillary reactivity shortly after ther apy is crucial for survival. Surgical evacuation of an intracranial mass, u nilateral FDPs, early intervention, and younger age are related to better c hances of survival or recovery. The prognosis of patients with FDPs after t rauma, stroke, and previous elective intracranial surgery is similar.