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One-year outcome following craniotomy for traumatic hematoma in patients with fixed dilated pupils
D E Sakas1, M R Bullock, G M Teasdale
1Department of Neurosurgery, University of Glasgow, Scotland.
Insights
Acute subdural hematoma significantly worsens survival outcomes in patients with traumatic brain injury and bilateral fixed dilated pupils. Early craniotomy is crucial for improving quality of survival.
Area of Science:
- Neurosurgery
- Trauma Surgery
- Neurology
Background:
- Bilateral fixed dilated pupils indicate severe brain injury.
- Craniotomy is a critical intervention for traumatic hematomas.
Purpose of the Study:
- To identify factors influencing survival quality after craniotomy for traumatic hematoma.
- To establish management criteria for patients with bilateral fixed dilated pupils.
Main Methods:
- Studied 40 patients undergoing craniotomy for traumatic hematoma.
- Correlated clinical and CT scan data with 1-year outcomes.
- Utilized chi-square test for statistical analysis.
Main Results:
- Functional recovery rate was 25%, mortality rate was 43%.
- Subdural hematoma associated with higher mortality (64%) vs. extradural hematoma (18%).
- Factors increasing mortality included older age, delayed surgery (>3 hours), basal cistern compression, and subarachnoid hemorrhage.
Conclusions:
- Acute subdural hematoma is the primary predictor of poor outcomes in patients with unresponsive pupils.
- No survivors observed with surgery >6 hours post-pupillary dilation loss, age >65, or absent motor response.
- Motor response is an unreliable mortality predictor, except in cases of absent motor response.
Abstract:
Forty consecutive patients who underwent craniotomy for traumatic hematoma after developing bilateral fixed dilated pupils were studied to determine the factors influencing quality of survival and to seek criteria for management. Clinical and computerized tomography (CT) data were correlated with outcome 1 year after craniotomy. The functional recovery (good outcome or moderate disability) rate was 25%, with a mortality rate of 43%. Patients with subdural hematoma had a higher mortality rate (64%) compared to patients with extradural hematoma (18%) (chi-square test, p > 0.05). Other factors associated with markedly increased morbidity and mortality were increasing age (> 20 years), a prolonged interval (> 3 hours) between loss of pupillary reactivity and craniotomy, compression of basal cisterns, and presence of subarachnoid hemorrhage on CT. There were no survivors among patients exhibiting any of the following features: surgery 6 hours or more after bilateral loss of pupillary reactivity; age greater than 65 years; or absent motor response. Apart from the latter group, the nature of motor response (before pharmacological paralysis and intubation) was not a reliable predictor of mortality. The results suggest that the presence of an acute subdural hematoma is the single most important predictor of negative outcome in patients with bilateral unresponsive pupils.