Bilateral fixed dilated pupils? Operate if extradural!

Almost two-thirds of patients with extradural haematoma and bilateral fixed dilated pupils survived after surgery, with over half having a good outcome

 

pupilsiconNeurosurgeon, HEMS doctor, and all round good egg Mark Wilson was on the RAGE podcast recently and mentioned favourable outcomes from neurosurgery in patients with extradural (=epidural) haematomas who present with bilateral fixed dilated pupils (BFDP). Here’s his paper that gives the figures – a systematic review and meta-analysis.

A total of 82 patients with BFDP who underwent surgical evacuation of either subdural or extradural haematoma were identified from five studies – 57 with subdural (SDH) and 25 with extradural haematomas (EDH).

In patients with EDH and BFDP mortality was 29.7% (95% CI 14.7% to 47.2%) and 54.3% had a favourable outcome (95% CI 36.3% to 71.8%).

Only 6.6% of patients with SDH and BFDP had a good functional outcome.

Clearly there is potential for selection bias and publication bias, but these data certainly suggest an aggressive surgical approach is appropriate in some patients with BFDP.

The authors comment on the pessimism that accompanies these cases, which potentially denies patients opportunities for recovery:


“We believe that 54% of patients with extradural haematoma with BFDPs having a good outcome is an underappreciated prognosis, and the perceived poor prognosis of BFDPs (from all causes) has influenced decision making deeming surgery inappropriately futile in some cases.”


Scotter J, Hendrickson S, Marcus HJ, Wilson MH.
Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis.
Emerg Med J 2014 e-pub ahead of print Nov 11;:1–7


Primary objective To review the prognosis of patients with bilateral fixed and dilated pupils secondary to traumatic extradural (epidural) or subdural haematoma who undergo surgery.

Methods A systematic review and meta-analysis was performed using random effects models. The Cochrane Central Register of Controlled Trials and PubMed databases were searched to identify relevant publications. Eligible studies were publications that featured patients with bilateral fixed and dilated pupils who underwent surgical evacuation of traumatic extra-axial haematoma, and reported on the rate of favourable outcome (Glasgow Outcome Score 4 or 5).

Results Five cohort studies met the inclusion criteria, collectively reporting the outcome of 82 patients. In patients with extradural haematoma, the mortality rate was 29.7% (95% CI 14.7% to 47.2%) with a favourable outcome seen in 54.3% (95% CI 36.3% to 71.8%). In patients with acute subdural haematoma, the mortality rate was 66.4% (95% CI 50.5% to 81.9%) with a favourable outcome seen in 6.6% (95% CI 1.8% to 14.1%).

Conclusions and implications of key findings Despite the poor overall prognosis of patients with closed head injury and bilateral fixed and dilated pupils, our findings suggest that a good recovery is possible if an aggressive surgical approach is taken in selected cases, particularly those with extradural haematoma.

3 thoughts on “Bilateral fixed dilated pupils? Operate if extradural!”

  1. It’s refreshing to hear Mark talk on this topic. The pessimism-nihilism in TBI can infect the resus room, and it’s difficult to reverse.
    However, I couldn’t agree more that the issue of selection/publication bias looms over this headline- grabbing statistic. Sadly this bias is probably immeasurable.
    Do we think that 54% of extradurals with fixed dilated pupils have a good outcome, or is that just a useful stick that we can beat our (less enlightened) neurosurgeons with?

    When all’s said and done, if it we me or my family, I’d be saying go for it. This paper should help us with that request so thank you.

  2. Is there a timeframe to this? At our hospital there is no neurosergeon, they are about two hours away.

  3. The authors comment in their discussion:

    “Although it was not possible to extract primary data on delay to surgery, several of the included studies did comment on their findings. Sakas et al reported that most patients with traumatic extradural or subdural haematoma undergoing surgery within 3h of their pupils becoming fixed and dilated survived.”

    For interest, the Australian rural neurotrauma guidelines recommmend local burr hole if the neurosurgical centre is more than two hours away after onset of pupillary enlargement – see p. 14 of https://www.surgeons.org/media/297365/PUB_090824_-_Neurotrauma_(Standard_Version).pdf

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