Hope When it Appears Hopeless: A Review of Need for Surgical Decompression in Severe TBI Patients with Fixed Dilated Pupils

Abstract

Background

The Glasgow Coma Scale (GCS) score of 3, the lowest on the scale, traditionally indicates a deep coma with poor prognosis and has often been considered a marker of futile care in traumatic brain injury (TBI). This perception, particularly when associated with bilateral fixed and dilated pupils (BFDP), has led to early decisions on limiting or withdrawing treatment.

Objective

This case series is studied to revisit and reevaluate the need for surgical decompression in patients who has a GCS of 3 with fixed dilated pupils and to understand if such patients can be given a chance when the prognosis appears dismal.

Materials and Methods

We present a case series of three patients with GCS 3 and BFDP who underwent timely neurosurgical intervention. All three cases defied conventional prognostic expectations, achieving meaningful neurological recovery. Additionally, we reviewed the existing literature on outcomes in this patient subset.

Results

Despite initial presentations suggestive of grave prognosis—including fixed pupils and large intracranial hemorrhages—early aggressive intervention (e.g., decompressive craniectomy, external ventricular drainage) resulted in progressive neurological improvement. All patients were discharged with GCS scores of E4VtM5 or higher, intact brainstem reflexes, and vital stability.

Conclusion

While a GCS of 3 with BFDP is associated with high mortality, it should not be viewed as universally incompatible with survival or recovery. Our case series, supported by literature, underscores the need for individualized management and delayed prognostication. Early surgical intervention, particularly in younger patients, may yield favorable outcomes and should be considered before labeling such cases as futile.

Keywords

decompression - decompressive craniectomy - fixed dilated pupils - GCS E1V1M1 - GCS E1VtM1 - severe TBI - severe traumatic brain injury

Ethical Approval

This study was conducted in accordance with the protocol approved by the Institutional Ethics Committee and adhered to the ethical standards set forth in the 1964 Helsinki Declaration and its later amendments. Required consents were obtained and no animal experiments were performed.

Publication History

Article published online:
22 September 2025

• References

• 1 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2 (7872): 81-84
• 2 Arfa Qasim, Lal Rehman, Iram Bokhari. et al. Outcome of patients with traumatic brain injury presenting with Glasgow Coma Scale of 3. J Ayub Med Coll Abbottabad 2009; 21 (02) 102-104
• 3 Lieberman JD, Pasquale MD, Garcia R. et al. Survival after severe head injury with Glasgow Coma Scale score of 3. Arch Surg 2003; 138 (04) 398-403
• 4 Turgeon AF, Lauzier F, Simard JF. et al; Canadian Critical Care Trials Group. Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ 2011; 183 (14) 1581-1588
• 5 Carney N, Totten AM, O'Reilly C. et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017; 80 (01) 6-15
• 6 Tien HC, Cunha JR, Wu SN. et al. Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?. J Trauma 2006; 60 (02) 274-278
• 7 Jennett B, Teasdale G. Aspects of coma after severe head injury. Lancet 1977; 1 (8017): 878-881
• 8 Fearnside MR, Cook RJ, McDougall P, McNeil RJ. The Westmead Head Injury Project outcome in severe head injury. A comparative analysis of pre-hospital, clinical and CT variables. Br J Neurosurg 1993; 7 (03) 267-279
• 9 Lieberman JD, Pasquale MD, Garcia R. et al. Use of GCS of 3 in trauma patients: is it predictive of death?. J Trauma 2003; 55 (03) 521-526
• 10 Shafi S, Diaz-Arrastia R, Madden C. et al. GCS score of 3: is there hope?. J Trauma 2005; 59 (06) 1308-1310
• 11 Hesdorffer DC, Ghajar J, Iacono L.. et al. Predicting outcome using GCS and pupil reactivity. J Neurotrauma 2007; 24 (08) 1433-1441
• 12 Coplin WM, Cullen NK, Policherla PN. et al. Prognostic factors in surgical management of traumatic brain injury. Neurosurgery 2001; 49 (04) 884-892
• 13 Zhang L, Yang J, Hu J. Outcome in TBI patients with GCS 3 and bilateral mydriasis after craniectomy. J Clin Neurosci 2008; 15 (07) 766-769
• 14 Bouras T, Stranjalis G, Korfias S. et al. Bilateral mydriasis and GCS 3: is there hope?. Neurosurg Rev 2012; 35 (04) 533-538
• 15 Papo I, Caruselli G, Luongo A. et al. Surgical treatment in patients with severe head trauma and bilateral fixed dilated pupils. Acta Neurochir (Wien) 2014; 156 (04) 729-735
• 16 Manley GT, Larson D, Neumann U. et al. Prognosis in severe traumatic brain injury. J Neurotrauma 2001; 18 (06) 569-575
• 17 Ganti L, Khalid H, Patel PS. et al. Outcomes in TBI with GCS 3 and bilateral fixed pupils. Crit Care Res Pract 2014; 2014: 731231
• 18 Chibbaro S, Tacconi L, Cebula H. et al. Decompressive craniectomy in severe head injury: a meta-analysis. Acta Neurochir Suppl (Wien) 2016; 121: 103-108
• 19 Cooper DJ, Rosenfeld JV, Gantner D. et al. Decompressive craniectomy in severe TBI. Neurosurg Clin N Am 2020; 31 (04) 611-623
• 20 Carney N, Totten AM, O'Reilly C. et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017; 80 (01) 6-15