Bilaterally absent pupillary responses: not always a bad sign

Pupillary responses are a simple test commonly used as a predictor of outcome after severe brain injury. It is also common for clinicians to associate bilaterally absent pupillary responses with very poor prognosis. We report a series of cases of severely brain injured children with bilaterally absent pupillary responses who had favourable outcomes. From a group of 89 patients with brain injury, 32 had bilaterally absent pupillary responses and six (four with traumatic brain injury and two with infective brain injury) subsequently had favourable outcomes. This represents 18.8% of patients and should be a reminder to clinicians that the clinical sign of bilaterally absent pupillary responses is not always associated with a hopeless outcome.