Nonetheless, the authors report that increasing age predisposing to worse outcome and increased mortality, while more than 50% of patients under 20-year-old (regardless of duration of mydriasis) recovered to be independent. In that series no patient presented dilated pupils for more than 9 h and no patient that was operated after 6 h with fixed dilated pupils survived. Long-term outcome was still negative, but we believe that our intervention was justified by the facts that non-neurological complications were the reason for the patient's death and she presented such an impressive short-term improvement.Ī known study has evaluated the effect of mydriasis duration on the outcoume of TBI patients treated with craniotomy. In our case, the young age of the patient and the relatively controllable range of ICP (17–27 mmHg) counted towards attempting further escalation with surgical treatment. Lasting bilaterally fixated pupils has been proposed as a decisive factor for non-escalation of treatment. Furthermore, due to excessive swelling of the underlying brain, we decided to perform dural incisions instead of flap durotomy. No bony bridge was left above the superior sagittal sinus in the area of the craniectomy undercutting and smoothing was also performed at the edge of the parietal bone. The patient was then operated using a wide decompressive craniectomy that encompassed bilaterally frontal and temporal areas, and extended as far as possible in the parietal bone. The pupils were checked immediately before the operation, but no recovery was observed. A reassessment of the patient's condition led to a decision for a final attempt at salvaging the patient by performing decompressive craniectomy. Initial decision was for conservative treatment using mannitol, hyperventilation, and barbiturate coma that controlled the ICP in a range of 17–27 mmHg, but despite that, mydriasis was resistant for >12 h. On the afternoon of the 7 th post-injury day, while in ICU care, the patient presented an increase in ICP (>25 mmHg with surges of >30) and bilateral non-reactive mydriasis (7 mm). Keywords: Brain edema, decompressive craniectomy, dilated pupils, intracranial hypertension, traumatic brain injury Wide decompressive craniectomy is viable for controlling refractory intracranial hypertension in hemodynamically stable patients. Delayed recurring infections lead to the patient's death due to sepsis after 3 months.Ĭonclusion:In light of recent studies, lasting bilateral mydriasis may not always be considered a decisive factor for non-escalation of treatment, as variability among TBI patients and outcomes has been demonstrated. The patient presented gradual improvement in her clinical condition. Wide decompressive craniectomy and dural incisions were performed. She was initially treated medically, but developed delayed secondary refractory intracranial hypertension and bilaterally dilated, non-reactive pupils for 12 h. Background:Lasting bilateral mydriasis and absence of pupillary light reflex following severe traumatic brain injury (TBI) are considered signs of irreversible brainstem damage and have been strongly associated with poor outcome.Ĭase Description:A young female patient presented with severe TBI, contusions, and diffuse brain edema.
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