Division of Neurosurgery, SBH Health System, Bronx, New York, USA.
Division of Neurosurgery, SBH Health System, Bronx, New York, USA; CUNY School of Medicine, New York, New York, USA.
World Neurosurg. 2022 Aug;164:e427-e435. doi: 10.1016/j.wneu.2022.04.118. Epub 2022 May 2.
Bilaterally fixed and dilated pupils (BFDP) in the setting of transtentorial herniation due to a space-occupying lesion have traditionally been considered a sign of futility. As a result, such patients may be denied life-saving decompressive surgery, resulting in very high mortality rates. We sought to determine the survival rate and functional outcomes in patients with transtentorial herniation and BFDP following emergency decompressive surgery.
This was a systematic review of MEDLINE, Embase, Cochrane, and Google Scholar databases, using a combination of 15 prespecified keywords, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology. Individual patient data were extracted, pooled, and analyzed.
Twenty-two studies totaling 503 patients were included. Study designs were as follows: prospective cohort (n = 1), retrospective cohort (n = 15), and case report (n = 6). Nearly two thirds of patients (67.7%) were male. The mean age was 41 years (range = 3-82). The median preoperative Glasgow coma scale was 3 (range = 3-6). Nearly two thirds (66.9%) underwent surgical decompression within 2 hours of pupillary changes. The mean follow-up was 7 months (range = 1-40). Two thirds (67%) died. Among survivors, 50.5% had severe disability (Glasgow outcome scale = 2-3), while 49.5% had a good outcome (Glasgow outcome scale 4-5), representing 17% of the whole population. Given the methodological limitations, the prognostic value of age, Glasgow coma scale, and time to surgery could not be determined.
The literature suggests a rate of favorable recovery approaching 17% following decompressive surgery in patients with transtentorial herniation and BFDP, secondary to space-occupying lesions. In the setting of stroke or trauma, the clinical finding of BFDP should not be solely relied on as an indicator of futility. Prospective studies are warranted.
由于占位性病变导致的颅后窝疝出现双侧固定性和扩张性瞳孔（BFDP）传统上被认为是无效的迹象。因此，此类患者可能会被拒绝进行救命的减压手术，从而导致极高的死亡率。我们旨在确定因占位性病变导致颅后窝疝和 BFDP 的患者接受紧急减压手术后的存活率和功能预后。
这是对 MEDLINE、Embase、Cochrane 和 Google Scholar 数据库的系统评价，根据系统评价和荟萃分析的首选报告项目，使用了 15 个预设关键字的组合。提取、汇总和分析了个体患者的数据。
共纳入 22 项研究，总计 503 例患者。研究设计如下：前瞻性队列研究（n=1）、回顾性队列研究（n=15）和病例报告（n=6）。近三分之二的患者（67.7%）为男性。平均年龄为 41 岁（范围=3-82）。术前格拉斯哥昏迷评分中位数为 3（范围=3-6）。近三分之二（66.9%）的患者在瞳孔改变后 2 小时内接受了手术减压。平均随访时间为 7 个月（范围=1-40）。三分之二（67%）的患者死亡。幸存者中，50.5%有严重残疾（格拉斯哥结局量表=2-3），而 49.5%有良好结局（格拉斯哥结局量表 4-5），占总人口的 17%。鉴于方法学上的限制，无法确定年龄、格拉斯哥昏迷量表和手术时间的预后价值。
文献表明，因占位性病变导致的颅后窝疝和 BFDP 患者接受减压手术后，有接近 17%的患者恢复良好。在中风或创伤的情况下，BFDP 的临床发现不应仅作为无效的指标。需要进行前瞻性研究。
