Are Bilaterally Fixed and Dilated Pupils the Kiss of Death in Patients with Transtentorial Herniation? Systematic Review and Pooled Analysis

- OBJECTIVE: Bilaterally fixed and dilated pupils (BFDP) in the setting of transtentorial herniation due to a spaceoccupying lesion have traditionally been considered a sign of futility. As a result, such patients may be denied life-saving decompressive surgery, resulting in very high mortality rates. We sought to determine the survival rate and functional outcomes in patients with transtentorial herniation and BFDP following emergency decompressive surgery. - METHODS: This was a systematic review of MEDLINE, Embase, Cochrane, and Google Scholar databases, using a combination of 15 prespecified keywords, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology. Individual patient data were extracted, pooled, and analyzed. - RESULTS: Twenty-two studies totaling 503 patients were included. Study designs were as follows: prospective cohort (n = 1), retrospective cohort (n = 15), and case report (n = 6). Nearly two thirds of patients (67.7%) were male. The mean age was 41 years (range = 3-82). The median preoperative Glasgow coma scale was 3 (range = 3-6). Nearly two thirds (66.9%) underwent surgical decompression within 2 hours of pupillary changes. The mean follow-up was 7 months (range [ 1-40). Two thirds (67%) died. Among survivors, 50.5% had severe disability (Glasgow outcome scale = 2-3), while 49.5% had a good outcome (Glasgow outcome scale 4-5), representing 17% of the whole population. Given the methodological limitations, the prognostic value of age, Glasgow coma scale, and time to surgery could not be determined. - CONCLUSIONS: The literature suggests a rate of favorable recovery approaching 17% following decompressive surgery in patients with transtentorial herniation and BFDP, secondary to space- occupying lesions. In the setting of stroke or trauma, the clinical finding of BFDP should not be solely relied on as an indicator of futility. Prospective studies are warranted.