A benign cause for a unilateral dilated pupil in a critical care patient

Krovvidi, Hari; Thillaivasan, A.

doi:10.1017/s0265021508003840

Cited by 14 publications

(9 citation statements)

References 2 publications

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“…Although anisocoria has been considered as a benign event in a critical care patient,[10] our case suggests that anisocoria in a subset of the population may actually be an impending neurologic emergency. Authors think it appropriate to believe that one should exert extra caution about the rapidity of fluid resuscitation in the management of a case of old TBI.…”

Section: Discussionmentioning

confidence: 88%

Postoperative acute anisocoria and old traumatic brain injury

et al. 2011

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Anisocoria is an uncommon entity in general postoperative intensive care. We present a case of a 45-year-old man suffering from severe acute pancreatitis with a past history of traumatic brain injury (TBI), who developed hypertension, bradycardia and anisocoria soon after re-exploration surgery under general anaesthesia. Computed tomography showed no new lesion. Measures directed towards reducing intracranial pressure resulted in amelioration in about 12h. The possible role of old TBI in the causation of anisocoria during general anaesthesia and resuscitation has been explored in this report.

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Section: Discussionmentioning

confidence: 88%

Postoperative acute anisocoria and old traumatic brain injury

et al. 2011

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“…Most cases were attributed to an improperly fitting face mask either from facial weakness [1] or a faulty seal on the mask [3-5,8,10], which we believe was the case in our patient. Faulty nebulizer circuit [2,13], and mechanical contamination of the nebulizer with the eye [9] were also cited as a potential cause. The remainder of the cases did not have a clear etiology.…”

Section: Discussionmentioning

confidence: 99%

Dont Believe Your Eyes- Ipratropium Induced Mydriasis: A Case Report and Review of the Literature

Pennington¹,

Louis²

2016

Gen Med (Los Angeles)

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Unilateral fixed mydriasis can be an ominous sign; however in many cases, it is benign and represents pharmacologic mediated action on the iris dilator or sphincter. Differentiation between pharmacologic mediated anisocoria and physiologic anisocoria can be challenging but may save on costly imaging. An 83 year-old woman was admitted with critical limb ischemia and subsequently developed respiratory failure treated with positive pressure ventilation and ipratropium nebulizers. She was noted to have left unilateral mydriasis without other neurologic deficits. Brain magnetic resonance imaging with MR angiography showed no evidence for a mass lesion or posterior communicating artery aneurysm. Her anisocoria self-resolved within 36 hours after nebulizer treatments were stopped. Ipratropium bromide is one of the most common medications used in the hospital setting and should be consider as a possible etiology when examining patients with unilateral mydriasis in the absence of other neurologic findings.

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“…Considering the changes noted on the first CT scan (Figures 1A through 1C), the most likely explanation for unilateral mydriasis was increased ICP causing uncal herniation and unilateral cranial nerve III compression [5]. The elevated concentration of carbonic acid and hydrogen ions from dissolved CO 2 produces dilatation of the cerebral arteries, leading to increased cerebral blood flow and elevation of ICP [2,6]. The direct correlation between paCO 2 causing cerebral vascular dilation has been well-documented in animal models also producing increased ICP [6].…”

Section: Discussionmentioning

confidence: 99%

Hypercapnic cerebral edema presenting in a woman with asthma: a case report

Joyce

McGee

2011

J Med Case Reports

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IntroductionCommon causes of non-traumatic acute cerebral edema include malignant hypertension, hyponatremia, anoxia, and cerebral vascular accident. The computed tomographic images and data obtained during care of the patient described in this case report provide evidence that hypercarbia can cause increased intracranial pressure and coma without permanent brain injury. Partial pressure of carbon dioxide evaluation for coma is essential to provide faster diagnosis and therapeutic correction in certain common critical disease states. We present the case of a patient in a coma associated with cerebral edema during a typical asthma exacerbation with hypercapnic respiratory failure.Case presentationAn obese 63-year-old African American woman with asthma presented to our hospital with facial swelling and shortness of breath. Immediately following intubation for hypercapnic respiratory failure, she was noted to have a dilated, unresponsive right pupil. An emergent computed tomographic head scan revealed that she had increased intracranial pressure. A neurosurgeon agreed with the computed tomography interpretation and recommended no surgical intervention. The patient's respiratory acidosis was corrected with ventilatory management over several hours in the intensive care unit. Nine and one-half hours later a follow-up head computed tomographic scan was read as normal without cerebral edema. At 12 hours, the patient's right pupil was 5 mm in diameter and reactive. By 24 hours, her pupils were symmetrically equal and reactive. Her symptoms had improved, and she was extubated. A brain magnetic resonance imaging scan revealed no abnormalities.ConclusionAlteration of consciousness related to hypercapnia during respiratory failure is not generally thought to be related to cerebral edema. Respiratory acidosis resulting from hypercarbia is known to produce carbon dioxide narcosis and coma, but no current treatment algorithm suggests that rapid hypercapnia correction can be critical to neurologic outcome. To the best of our knowledge, our case is a unique example of the physiological changes that may occur in relation to arterial carbon dioxide concentration in the normal brain in the setting of typical hypercapnic respiratory failure. Correction of respiratory acidosis reversed the neurologic symptoms and physiology causing cerebral edema and coma in our patient. Rare similar cases have been sporadically reported in the medical literature, typically in children. Our case is also unusual in that rapid deterioration and clinical status were directly observed on simultaneous computed tomographic scans. Had this patient been found unresponsive, or had she had brief respiratory or cardiac arrest, the scan could have been interpreted as global anoxic injury leading to a different therapeutic course.

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A benign cause for a unilateral dilated pupil in a critical care patient

Cited by 14 publications

References 2 publications

Postoperative acute anisocoria and old traumatic brain injury

Postoperative acute anisocoria and old traumatic brain injury

Dont Believe Your Eyes- Ipratropium Induced Mydriasis: A Case Report and Review of the Literature

Hypercapnic cerebral edema presenting in a woman with asthma: a case report

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