Transcranial doppler ultrasonography cerebral blood flow dynamics study of neurosurgical patients in peri-agonal period with fixed dilated or non-reacting pupils.

INTRODUCTION: Fixed dilated and unreactive pupils are a harbinger of imminent death in neurosurgical patients, signifying that the brainstem is not functioning. Transcranial Doppler (TCD) ultrasonography is a noninvasive, bedside method of determining the flow velocities in the basal cerebral arteries, used extensively in various neurosurgical conditions. AIMS AND OBJECTIVES: To study the cerebral blood flow dynamics of neurosurgical patients in peri-agonal period with fixed dilated or non reacting pupils using TCD. MATERIALS AND METHODS: Repeated TCD studies were done in patients with fixed dilated or unreactive pupils in a tertiary care, neurosurgical hospital over a year, recording the various waveforms and indices as Pulsatility Index (PI), Resistivity Index, Peak systolic flow velocity (PSV), End diastolic flow velocity (EDV), Mean cerebral blood flow velocity (MCBFV) of their middle cerebral artery in their peri-agonal period. The subsequent change in the indices as the patients died or improved was analyzed. RESULTS: A total of 104 TCD studies were done on 57 patients. Mean initial PI and MCBFV in the patients that died were 1.52 ± 0.76 and 28.55 ± 14.92 cm/sec respectively; and in the patients that showed neurosurgical recovery was 1.11 ± 0.28 and 36.52 ± 8.56 cm/sec respectively. Four out of 57 patients showed neurosurgical recovery and all of them had an initial PI less than 1.4 and they showed decrement in PI and increment in MCBFV on subsequent TCD study. The specificity and positive predictive value of the TCD waveform in predicting death was 100%, however, it had low sensitivity (47.17%) and negative predictive value (12.5%). CONCLUSION: The various indices and waveforms of TCD can be useful in assessing the cerebral blood flow dynamics in patients with various traumatic and non-traumatic ailments in the peri-agonal period; and hence help in their management as well as in the confirmation of brainstem death.

Results of single burr hole drainage for acute subdural hematoma with non-reactive pupil.

AIM: To investigate the effects of emergency burr hole drainage for acute subdural hematoma (ASDH) with bilateral non-reactive pupils. MATERIAL AND METHODS: A retrospective study was conducted by reviewing medical records from 1998 to 2007. Patients meeting the following criteria were included: 1) head injury with unconsciousness (Glasgow Coma Scale score 8); 2) bilateral non-reactive pupils on arrival; 3) ASDH with disappearance of basal cistern on computed tomography (CT); and 4) performance of emergency single burr hole drainage. Subjects were divided into survival and non-survival groups. RESULTS: Pupil size on the small side was significantly smaller in the survival group than in the non-survival group. All pupils on the small side in the survival group were 4 mm. CONCLUSION: Emergency burr hole drainage should still be considered in patients with ASDH showing bilateral non-reactive pupils and one pupil 4 mm.

Relationship between abnormal pupillary reactivity and the outcome of a psychotropic drug overdose.

OBJECTIVE: The association between abnormal pupil reactivity (abnormal) and the outcome among patients with psychotropic drug overdose (OD) was retrospectively investigated. METHODS: The study included patients that had experienced an OD between January and December 2007. The subjects were divided into 2 groups, namely, abnormal and normal groups. RESULTS: There were 12 subjects in the abnormal and 74 subjects in the normal group. Glasgow Coma Scale in the abnormal was significantly smaller that that in the normal group. An average quantity of ingested tranquilizer per subject in the abnormal was significantly larger that those in the normal group. However, the duration of admission and survival rates between the two groups were not significantly different. CONCLUSION: The patients that experienced an OD, who demonstrated abnormal pupil reactivity, tended to have ingested larger amounts of drugs while also demonstrating severe unconsciousness. However, the patients with abnormal pupil reactivity had a favorable outcome.

Survival of trauma patients with coma and bilateral fixed dilated pupils.

BACKGROUND: Survival of patients with severe trauma presenting with Glasgow Coma Score (GCS) 3 and bilateral fixed dilated pupils is uncertain. Pre-hospital management of these patients affects the true measurement of the GCS and other factors may affect pupillary status. PATIENTS AND METHODS: A retrospective review was undertaken of all patients who were classified GCS 3 and had bilateral fixed dilated pupils on admission to a Level 1 Adult Trauma Centre between July 2001 and March 2005. Pre-hospital assessment, hospital interventions and outcomes were determined. RESULTS: Ninety-three patients fulfilled the criteria for inclusion into the study. There were 6 survivors who were all less than 28 years of age, had at least one GCS score above 3 in the pre-hospital phase and were more likely to have had an evacuable mass lesion on CT brain scan and undergo craniotomy. Of the 6 surviving patients, none had significant thoracoabdominal injuries. Four of the survivors had Glasgow Outcome Score (GOS) of 4 or 5. Time to hospital, mechanism of injury and pre-hospital haemodynamic parameters had no significant effect on survival. Of the 57 patients who were GCS 3 at the scene of the accident, post-basic resuscitation and on admission, none survived. CONCLUSION: Pre-hospital GCS scores, prior to the effects of intubation, sedation and paralysis should be given more attention when assessing prognosis in patients who are GCS 3 on admission. Trauma patients with GCS 3 persisting from the scene with bilaterally fixed dilated pupils have no appreciable chance of survival. Further interventions such as ICU admission and surgery may not be warranted. Physicians may need to consider stopping treatment and discussing organ donation.