Page 40 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 2
Multiple studies report poor outcome and increased mortality rates to be associated with pupillary abnormalities.45, 46, 48, 50 In normally bilateral reactive pupils a mortality rate of 23.5% and a good outcome in 1 out of 4 patients is reported 50 and in another study absence of pupillary response correlated with unfavorable outcome (OR3.16, 95% CI 1.38-7.25).46 In patients with gunshot wound to the head 96% and 100% died when having a unilateral dilated pupil or a medium fixed pupil.48 Another study found mortality rates in patients with bilaterally fixed dilated pupils of nearly 80% and good outcome in only 1.5% of patients.50 Other possibilities, like unilateral fixed dilated pupils showed good outcome in 27.5% and bilateral fixed, non-dilated pupils achieve good outcome in only 7.5%.50 Patients with both a GCS=3 and bilaterally fixed dilated pupils presented good outcome (GOS 4-5) after neurosurgery in 9.3%. In the overall group, difference in good outcome was found between field and post resuscitation GCS of 3 (8.7% vs. 4%).19 Patients with bilaterally fixed dilated pupils showed increased numbers of extra-axial bleedings (81.4% vs. 56.5%, P=0.002), midline shifts (70.0% vs. 24.2%, P<0.0001) and herniation (64.3% vs. 11.3%, P<0.0001) and ultimately higher mortality compared to patients with RP (100% vs. 42%, P<0.0001).45 Sometimes, patients with bilaterally fixed dilated pupils were not stable enough to undergo a CT scan.45
Aggressive presurgery medical treatment with single high mannitol dosage (90-106g) resulted in significant lower risks of death and persistent vegetative state (OR=0.016) with lower unfavorable outcome (57.1% vs. 95.5%). However at 1 year follow up, more patients survived with severe disabilities.51
One study showed survival was most positively linked to acute epidural hematomas, followed by cerebral contusions, and worst with acute subdural hematomas.47 Another study however, found no correlation between dominant lesions, presence of midline shift and outcome.46 Compression of basal cisterns was linked to death (OR3.24, 1.04- 10.12) and unfavorable outcome (OR: 2.74, 1.17-6.42).19, 46 For patients with gunshot wounds to the head, especially transventricular or bihemispheric central type trajectory, and bilobar or multilobar wounds are suggested as predictive factors of high morbidity and mortality.48
Other factors mentioned to be associated with lower survival or unfavorable prognosis are: higher age 19, 47, 50, 51 and ICP.50 Alcohol, gender, mechanism of injury, hypotension on admission, and extracranial injuries are mentioned not to be related with outcome.50
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