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

Bilaterally fixed and dilated pupils (BFDP) in the setting of transtentorial herniation due to a space-occupying 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. 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. 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. 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.