Division of Neurosurgery, SBH Health System, New York, New York, USA.
Division of Neurosurgery, SBH Health System, New York, New York, USA; CUNY School of Medicine, New York, New York, USA.
World Neurosurg. 2022 Nov;167:e444-e450. doi: 10.1016/j.wneu.2022.08.036. Epub 2022 Aug 12.
Bilaterally fixed and dilated pupils in the setting of transtentorial herniation have traditionally been considered a sign of futility. Such patients are often denied life-saving surgery based on the premise that meaningful functional recovery would be extremely unlikely. We sought to determine the survival and functional outcome in a cohort of patients who underwent aggressive medical and surgical management.
Charts of all patients managed by a single surgeon over a 42-month period were retrospectively reviewed. Functional outcome was determined using modified Rankin Scale (mRS). Outcome was classified as good (mRS score 0-3), acceptable (mRS score 4), or poor (mRS score 5-6).
Patients were 7 men and 2 women with a mean age of 36 years (range, 16-66 years). Etiologies included stroke (4 patients), traumatic brain injury (4 patients), and malignant cerebral edema (1 patient). Preoperative Glasgow Coma Scale scores ranged from 3 to 7, and midline shift was 7-16 mm. All patients received emergency osmotic therapy before decompressive surgery. Time to surgery (from pupillary changes) was <150 minutes for all patients (median 94 minutes; range, 50-148 minutes). At 3 months, 5 patients (55.6%) had recovered, achieving a good (n = 3) or acceptable (n = 2) outcome. The other 4 patients failed to recover and ultimately died of their injury.
In well-selected patients with transtentorial herniation and bilaterally fixed and dilated pupils, aggressive and timely medical and surgical management may lead to substantial rates of survival and favorable functional outcome. Preconceived notions of a universally grim prognosis in such patients can lead to self-fulfilling prophecies.
在颅后窝疝的情况下，双侧固定性和扩张性瞳孔传统上被认为是无效的迹象。此类患者通常会因功能恢复的可能性极小而被拒绝接受挽救生命的手术。我们试图确定在接受积极的医疗和手术治疗的患者队列中的存活率和功能结果。
回顾性分析了一名外科医生在 42 个月期间管理的所有患者的病历。使用改良 Rankin 量表（mRS）确定功能结果。结果分为良好（mRS 评分 0-3）、可接受（mRS 评分 4）或不良（mRS 评分 5-6）。
患者为 7 名男性和 2 名女性，平均年龄为 36 岁（范围 16-66 岁）。病因包括中风（4 例）、创伤性脑损伤（4 例）和恶性脑肿胀（1 例）。术前格拉斯哥昏迷量表评分范围为 3 至 7 分，中线移位为 7-16 毫米。所有患者在减压手术前均接受紧急渗透性治疗。所有患者的手术时间（从瞳孔变化开始）均<150 分钟（中位数 94 分钟；范围 50-148 分钟）。在 3 个月时，5 名患者（55.6%）已康复，取得了良好（n=3）或可接受（n=2）的结果。其余 4 名患者未能康复，最终因伤死亡。
在经过精心选择的颅后窝疝和双侧固定性和扩张性瞳孔的患者中，积极且及时的医疗和手术治疗可能会导致高存活率和良好的功能结果。在这种患者中，对普遍严峻预后的先入为主的观念可能会导致自我实现的预言。
