Long Term Outcome in Patients with Severe Head Injury and Bilateral Fixed Dilated Pupils

ORIGINAL ARTICLE Long Term Outcome in Patients with Severe Head Injury and Bilateral Fixed Dilated Pupils J. Sousa, R.R. Sharma, S.J. Pawar, A. Mahap...
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ORIGINAL ARTICLE

Long Term Outcome in Patients with Severe Head Injury and Bilateral Fixed Dilated Pupils J. Sousa, R.R. Sharma, S.J. Pawar, A. Mahapatra, S.D. Lad

Department of Neurosurgery Khoula Hospital Muscat 116, Sultanate of Oman.

Summary Patients with severe head injury with bilateral dilated unreactive pupils are considered to have a grave prognosis. Hence proper planning and aggressive management becomes mandatory for achieving good results. We present the outcome of consecutive 166 patients with severe head injury, admitted between January 1996 and December 2000 and analysed retrospectively. All the patients had an initial GCS of 8 or less and post resuscitation bilateral dilated unreactive pupils. Our aim was to analyze the long term outcome in these patients and identify the other significant prognostic factors. Of the 166 patients, 42 (25.30%) had a functional outcome (good recovery in 10.24%, moderate disability in 15.06%), and 124 (74.69%) had a poor outcome (death in 58.43% and severe disability in 16.26% of cases). There were 45 patients with polytrauma and 24 of these patients (53.33%) succumbed to the injuries. Obliteration of the basal cisterns and contusion were the common CT scan findings. Factors adversely affecting the survival included age of the patient, polytrauma with shock, initial GCS of 3 or 4, and compression of the basal cisterns on the initial CT scans. At follow up, most of the patients with a functional outcome showed a significant improvement in their motor function but continued to have neuro-behavioral and cognitive deficits.

Key words : Pupil, Unreactive, Dilated, Severe head injury, Outcome.

Neurol India, 2002; 50 : 430-435

Introduction Generally, patients with severe head injury, presenting with bilateral dilated unreactive pupils are considered to have a grave prognosis.1-3 Such a presentation Correspondence to : Dr. R.R. Sharma, PO Box No 397, Al Harthy Complex, Muscat 118, Sultanate of Oman. E-mail : [email protected]

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suggests the possibility of a significant brain injury. Although, many studies have identified the prognostic factors in severe head injuries, few studies have focussed on the severe head injury patients with bilateral dilated unreactive pupils in predicting the long term outcome.4-10 This study was planned to determine the outcome in this group of patients and also to identify other prognostic factors, to help plan further line of management. 430

Long Term Outcome in Patients with Severe Head Injury

Material and Methods Clinical information was obtained through retrospective analysis of the 166 patients with bilateral fixed dilated pupils, admitted at the National Neurosurgical Center, Khoula Hospital, Sultanate of Oman, over 5 year period from January 1996 through to December 2000. The patients were followed up regularly at the neurosurgical out patient clinic to determine the ultimate outcome. Follow-up ranged from 6-40 months (mean 24 months). During the study period, 1245 patients were admitted in the neuro intensive care unit with severe head injury (Glasgow Coma Score 8 or less). 166 patients were admitted with post resuscitation bilateral dilated and unreactive pupils. There were 148 males and 18 females. Demographically, 136 patients were adults and 30 were children (upto the age of 14 years). All the patients had a pupillary size of 4 mm or more. Patients having direct ocular trauma or indirect optic nerve injury were excluded from the study. Prior to the elective ventilation, post resuscitation, the glasgow coma score (GCS)11 was carefully recorded in these patients. CT scans were performed in all cases, as soon as possible. ICP monitoring was carried out in 62 patients as per our ICP protocol. Both intraventricular and intraparenchymal methods were used depending on the suitability. Patients having ICP of > 20 mm Hg, received mannitol regularly. In patients with intraventricular catheter, CSF drainage was regularly used as a modality to reduce ICP, when ICP was > 20 mm of Hg. Patients with significant focal mass lesions were subjected to surgical evacuation, provided, they were not in irreversible shock or diagnosed as brain stem death. Duration of ventilation and ICP monitoring was reviewed on daily basis and continued as per the need. Blood gases, cerebral perfusion pressure (CPP) and electrolytes were monitored carefully. Patients requiring ventilation longer than 2 weeks, often required tracheostomy. Outcome was assessed following the criterion of glasgow outcome scale (GOS).12 Patients were followed in out patient clinic on regular basis. Functional outcome was defined as a good clinical outcome or a moderate disability as described by Andrews and Pitts, in 1991.1

Results a) Modes of Injury : 51 patients (30.7%) out of the total 166 were pedestrians involved in road accidents, 82 (49.4%) were passengers in cars involved in high speed road accidents. Twenty-nine patients (17.4%)

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had a fall from a height and in 4 patients (2.4%) the injuries were due to a fall from a camel. The latter is unique to this region, where camel racing is a common sport, with children acting as the camel jockeys. b) CT scan findings and Outcome : Among the focal mass lesions, a single small brain contusion was the commonest CT scan finding recorded in 49 patients (31.9 %). A large cerebral contusion was seen in 4 cases. This was followed by an acute subdural hematoma (SDH) in 48 patients (28.9 %). The SDH was small in 38 cases and large in 10 cases. 16 (9.6%) patients had an extradural hematoma (EDH). In only 9 cases EDH was significant enough to be evacuated. Other CT scan findings included, scattered small contusions in 20 patients (12%) and traumatic sub arachanoid hemorrhage (TSAH) in 14 cases (8.4%). Six patients (3.6%) had generalized brain swelling. Partial or complete obliteration of basal cistern was recorded in 132 cases (80%). Overall 124 patients had a poor outcome, among them 118 (95.1%) had obliteration of the basal cistern on the CT scans, whereas a group of 42 patients with a functional outcome only 14 cases (33%) had obliteration of basal cisterns. c) GCS and Outcome : Of the 76 patients with initial GCS score of 3 or 4, 63 patients (82.8%) had a poor outcome (p 40 years of age, who had functional outcome of cases. This may be a reflection of the mechanism of injury, associated injuries and the functional reserve in these patients to sustain the stress. Patients with decerebrate rigidity are reported to have a poor outcome.6,32 Bricolo et al reported a good outcome only in 16% cases.32 In our study, 81.8% patients with an extensor response had a poor outcome with 18.2% achieved a good functional outcome. Various biochemical parameters like serum catecholamine levels,33 serum glucose levels,34 coagulation parameters.35 CK-BB (Creatinine Kinase BB)36 have

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Sousa et al

also been studied to predict the outcome in patients with severe head injury. Timing of the outcome assessment is also very important, since premature assessment of outcome may underestimate the recovery.37 Hence, it is also important that a persistent vegetative state should not be diagnosed, till the end of the first year after the trauma.38 Usually, a patient classified as functional outcome will have achieved this status by the first 6 months.37 Heiden et al reported that 68% of the patients classified as severe disability at 1 month, had improved to the category of moderate disability or a good recovery at 6 months and 72% had achieved this status at 1 year. Interestingly, while the initial linguistic impairment is largely due to a dominant hemisphere injury, long term recovery of language function is most dependent on the duration of the coma.39

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Conclusion

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Patients with severe head injury and unreactive dilated pupils, should be aggressively managed. Age, shock on admission, and obliteration of basal cistern on the initial CT scan determine the survival. The best predictors of a favourable outcome in severe head injury patients with fixed dilated pupils include young age, Glasgow coma scale above 4/15, stable vital signs in the normal ranges, and the presence of basal cisterns and absence of midbrain shift on the initial CT scans. The unreliable predictors were initial ICP recordings, the presence of DAI or SAH on the initial CT scans. Surprisingly, ICP failed to predict the outcome. GCS of 3 (M = 1 or 2) is associated with a poor outcome, Patients with bilateral fixed dilated pupils and EDH should be operated upon as a significant number of these patients in our study had a functional outcome.

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Accepted for publication : 15th December, 2001.

Neurology India, 50, December 2002

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