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.

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To assess the relationship between posttraumatic cerebral hyperemia and focal cerebral damage, the authors performed cerebral blood flow mapping studies by single-photon emission computerized tomography (SPECT) in 53 patients within 3 weeks of brain injury. Focal zones of hyperemia were present in 38% of patients. Hyperemia was correlated with clinical features and early computerized tomography (CT) and magnetic resonance (MR) imaging performed within 48 hours of the SPECT study and late CT and MR studies at 3 months. The hyperemia was observed primarily in structurally normal brain tissue (both gray and white matter), as revealed by CT and MR imaging, immediately adjacent to intraparenchymal or extracerebral focal lesions; it persisted for up to 10 days, but was never seen within the edematous pericontusional zones. The percentage of patients in the hyperemic group having brief (< 30 minutes) or no loss of consciousness was significantly higher than in the nonhyperemic group (twice as high, p < 0.05). Other clinical parameters were not significantly more common in the hyperemic group. The mortality of patients with focal hyperemia was lower than that of individuals without it, and the outcome of survivors with hyperemia was slightly better than patients without hyperemia. These results differ from the literature, which suggests that global post-traumatic hyperemia is primarily an acute, malignant phenomenon associated with increased intracranial pressure, profound unconsciousness, and poor outcome. The current results agree with more recent studies which show that posttraumatic hyperemia may occur across a wide spectrum of head injury severity and may be associated with favorable outcome.