Petrov Mihail, Sakelarova Teodora, Velinov Nikolay, Dimitrova Maria, Gabrovsky Nikolay
Neurological Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine "N. I. Pirogov", Sofia, BGR.
Neurology, University Multiprofile Hospital for Active Treatment and Emergency Medicine "N. I. Pirogov", Sofia, BGR.
Cureus. 2024 Sep 10;16(9):e69133. doi: 10.7759/cureus.69133. eCollection 2024 Sep.
Bilateral dilated pupils are an ominous clinical sign of brainstem dysfunction, which uniformly leads to a bad prognosis for the patient. In some rare instances in adult patients, it could be reversible. We present a clinical case of an elderly stroke patient with bilateral dilated pupils with a surprisingly favorable clinical outcome. An 80-year-old female patient presented in the emergency department in a coma, areflexia, and bilaterally dilated non-reactive pupils. One and a half hours ago the patient suddenly lost consciousness and became unresponsive. A computed tomography (CT) scan showed a hyperdense basilar tip, and CT angiography confirmed the presence of a defect in the filling of the basilar tip and the bilateral P1 segments of the posterior cerebral arteries (PCA). The patient was ineligible for intravenous thrombolysis. Endovascular treatment was performed with partial recanalization of the basilar artery thrombolysis in cerebral ischemia (TICI) 2a. The diameter and light reactivity of patients' pupils are important parts of the neurological exam. A dilated pupil is an ominous sign associated with a severe prognosis and even worse if both pupils are dilated. Bilateral fixed dilated pupils could be present in basilar artery occlusion (BAO), i.e., basilar tip occlusion. This is explained by ischemia in the mesencephalon, where the nucleus of the oculomotor nerve lies. This ischemic stroke has the highest mortality rate, greater than 85%. The only proven treatment for BAO patients is recanalization with intravenous r-tPA (recombinant tissue plasminogen activator), intra-arterial r-tPA, or endovascular treatment. With adequate treatment, a good outcome can be obtained in up to 35%, and the mortality can be dropped to 40%. Patients with posterior circulation stroke, especially BAO, are still one of the hardest to diagnose on time. They require timely and coordinated efforts by an interdisciplinary team of neurologists, neuroradiologists and neurosurgeons. Timely recanalization within 12 hours and potentially up to 24 hours is the goal. This could lead to a favorable outcome. Loss of consciousness and bilateral fixed dilated pupils could be present in patients with BAO and shouldn't be accepted as a sign of a definite bad outcome. This definitely should not discourage treating physicians. All efforts should be focused on finding the right diagnosis in a timely manner. The differential diagnosis is crucial and may be the difference between life and death, especially in the context of BAO.
双侧瞳孔散大是脑干功能障碍的不祥临床体征，这一致预示着患者预后不良。在成年患者的一些罕见情况下，它可能是可逆的。我们呈现了一例老年中风患者双侧瞳孔散大但临床结局出奇良好的病例。一名80岁女性患者在急诊科昏迷，无反射，双侧瞳孔散大且无反应。1个半小时前患者突然失去意识且无反应。计算机断层扫描（CT）显示基底动脉尖部高密度影，CT血管造影证实基底动脉尖部及双侧大脑后动脉（PCA）P1段充盈缺损。该患者不符合静脉溶栓条件。进行了血管内治疗，基底动脉溶栓达到脑缺血再灌注分级（TICI）2a级部分再通。患者瞳孔的直径和对光反应是神经检查的重要部分。瞳孔散大是与严重预后相关的不祥体征，若双侧瞳孔都散大则预后更差。双侧固定散大瞳孔可能出现在基底动脉闭塞（BAO），即基底动脉尖部闭塞的情况下。这是由于动眼神经核所在的中脑缺血所致。这种缺血性中风死亡率最高，超过85%。对于BAO患者唯一经证实的治疗方法是用静脉重组组织型纤溶酶原激活剂（r - tPA）、动脉内r - tPA或血管内治疗进行再通。经过适当治疗，高达35%的患者可获得良好结局，死亡率可降至40%。后循环中风患者，尤其是BAO患者，仍然是最难及时诊断的群体之一。他们需要神经科医生、神经放射科医生和神经外科医生组成的跨学科团队及时且协同的努力。在12小时内甚至可能长达24小时内及时再通是目标。这可能带来良好结局。意识丧失和双侧固定散大瞳孔可能出现在BAO患者中，不应被视为确定的不良结局的标志。这绝对不应使治疗医生气馁。所有努力都应集中在及时做出正确诊断上。鉴别诊断至关重要，可能是生死之别，尤其是在BAO的情况下。
