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Surgical significance of prolonged fixed and dilated pupils in a case of non-traumatic, spontaneously regressing, acute subdural haemorrhage
  1. Raunak Jain1,
  2. Crystallynn Skye The1,
  3. Mary M Murphy2 and
  4. Anand S Pandit2
  1. 1Medical School, Faculty of Medical Sciences, University College London, London, UK
  2. 2Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
  1. Correspondence to Mr Anand S Pandit; a.pandit{at}


Bilaterally fixed and dilated pupils (BFDP) in traumatic acute subdural haematoma (ASDH) patients represent an ominous sign that portends irreversible brainstem injury and death. Whether patients with spontaneous ASDH and BFDP follow similar outcomes is unknown. We present a mid-60s man, found unconscious, with a Glasgow Coma Scale (GCS) of 4 following 8 days of headaches. Emergency CT imaging demonstrated a large right ASDH and the patient exhibited BFDP for >3 hours despite sedation and mannitol. Neurological improvement and spontaneously reduced SDH thickness were observed 10 hours postadmission, and he was later transferred for craniotomy and ASDH evacuation. His long-term outcomes were good: achieving independence in his activities of daily living and a GCS of 15. To the best of our knowledge, this is the first reported patient with a spontaneous, regressing ASDH and prolonged BFDP who clinically improved. This case raises important questions regarding factors used to determine prognosis and surgical viability for ASDH.

  • Neurosurgery
  • Neuro ITU
  • Coma and raised intracranial pressure

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  • RJ and CST are joint first authors.

  • MMM and ASP are joint senior authors.

  • Twitter @anandpandit00

  • Contributors ASP, RJ and CST composed the manuscript and prepared the figures. RJ and CST performed the literature review. ASP and MMM edited the manuscript and supervised the report.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer We can confirm that this manuscript and figures are our original work, and it is not being considered for publication at any other journal.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests As the supervising author I can confirm that all authors have met BMJ criteria for authorship and contribution and have no conflict of interest to disclose.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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