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CC BY 4.0 · Indian Journal of Neurotrauma
DOI: 10.1055/s-0045-1811659
Original Article

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

Authors

  • Tejas Narkhede

    1   Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

  • Rakshay Kaul

    1   Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

  • Sarvesh Yadav

    1   Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

  • Rajesh Meena 

    1   Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

  • Deepak Agrawal 

    1   Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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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

Introduction

The Glasgow Coma Scale (GCS), introduced by Teasdale and Jennett in 1974, remains one of the most widely used tools for assessing the level of consciousness in patients with traumatic brain injury (TBI).[1] A score of 3, the lowest possible on the scale, signifies deep coma with no eye opening, verbal response, or motor response. Traditionally, a GCS of 3 has been associated with extremely poor prognosis, and in many clinical contexts, it has been perceived as a near-certain predictor of mortality or devastating neurological outcome.[2]

However, this dogma has increasingly been challenged. Studies over the past two decades have revealed a more nuanced understanding of prognostication in severe TBI. While it is indisputable that GCS 3 patients exhibit high mortality rates, emerging evidence suggests that survival and even functional recovery, though rare, are not impossible. In a retrospective analysis by Lieberman et al, among patients presenting with a GCS of 3, approximately 13% survived, and some attained moderate recovery.[3] Similarly, Turgeon et al highlighted variability in outcomes based on age, pupillary reactivity, computed tomography (CT) findings, and early neurosurgical intervention, suggesting that GCS 3 should not be viewed as an absolute threshold for futility.[4]

The American Association of Neurological Surgeons and Brain Trauma Foundation guidelines also caution against early prognostic pessimism, recommending that decisions on withdrawal of care be delayed for at least 72 hours when feasible, especially in the absence of bilateral fixed and dilated pupils (BFDP) or brainstem areflexia.[5]

This article aims to critically analyze the prognostic implications of a GCS score of 3 in patients with TBI, examine the interplay of adjunct clinical variables, and explore whether modern data support or refute the traditional equivalence of GCS 3 with inevitable death. By reviewing both historical assumptions and contemporary outcome studies, we seek to provide an evidence-based framework for clinical decision-making in the management of these most critically injured patients.

Patients with GCS of 3 and BFDP have a dismal prognosis. These patients have suffered devastating brain injuries and tend to be hemodynamically unstable. Clinicians, however, are less likely to aggressively treat BFDP patients than RP patients.[6]

However, there is always an exception to everything in science. Here, we have a short case series of three patients that prove otherwise.


 

Case Series

Case 1

A 43-year-old female presented to the emergency department (ED) following a ground-level fall after slipping while walking. She experienced one episode of vomiting and was unconscious since the incident. On arrival, the primary survey revealed a compromised airway, and the patient was promptly intubated. Her blood pressure was 200/80 mm Hg with a pulse rate of 76/min. The GCS was E1VtM1 with bilaterally dilated, fixed pupils. Routine labs were within normal limits. Noncontrast CT (NCCT) head revealed intraventricular hemorrhage involving all ventricles with an enlarged fourth ventricle, and a right cerebellar cortical bleed extending slightly into the dorsal brainstem. Preoperatively, a right frontal external ventricular drain (EVD) was placed, followed by posterior fossa decompression with C1 arch removal and lax duroplasty using fascia lata.

Postoperatively, the patient improved to E1VtM5 with bilaterally nonreactive, sluggish pupils and EVD drainage of 100 mL on postoperative day (POD) 1. By POD 3, she was drowsy but improved to E3VtM6. On POD 6, she was weaned to continuous positive airway pressure (CPAP) but had poor tube tolerance, so a percutaneous tracheostomy was performed, and she was gradually weaned to room air. At present, she is alert with GCS E4VtM6, bilaterally sluggishly reactive pupils, and is vitally stable.


 

Case 2

A 53-year-old male presented following a road traffic accident on February 1, 2023, at approximately 12:30 hours. He experienced two episodes of loss of consciousness accompanied by vomiting. He was received in the ED at 14:00 hours with normal vital signs and a GCS of E2V2M5. Due to a threatened airway, the patient was intubated. On initial examination, GCS was E2V2M5 with sluggishly reactive pupils. Subsequently, his condition deteriorated to E1VtM1 with bilaterally dilated, nonreactive pupils. NCCT head revealed a right frontal bone fracture extending to the orbital roof and frontal sinus, right high frontal contusions, a left temporal contusion, and sulcal subarachnoid hemorrhage. The patient was shifted to the intensive care unit from the ED with a GCS of E2VtM4. Sedation was withheld for reassessment, revealing a persistent GCS of E1VtM1 and BFDP. At 21:00 hours, he underwent a right fronto-temporo-parietal decompressive craniectomy with lax duroplasty.

Postoperatively, his GCS improved to E1VtM4, with bilaterally nonreactive sluggish pupils. Within 48 hours, further improvement was noted to E3VtM5. A percutaneous tracheostomy was performed, and by POD 5, he was drowsy but responsive with GCS E3VtM6. He was weaned to CPAP and subsequently to room air. At discharge, the patient was alert with a GCS of E4VtM6, bilaterally sluggishly reactive pupils, and was vitally stable.


 

Case 3

A 45-year-old male was brought in following trauma of unknown mechanism on June 15, 2022. On arrival, he was hemodynamically stable with a GCS of E1VtM3. Due to a threatened airway, he was intubated. Initial examination revealed bilaterally reactive pupils with GCS E1VtM3. However, just prior to induction, his neurological status deteriorated to E1VtM1, and pupils became bilaterally dilated and nonreactive. The NCCT head revealed a large left-sided parietal epidural hematoma (EDH) measuring approximately 140 mL with a 9-mm midline shift. The patient was taken emergently to the operating room for surgical decompression. A left parietal EDH evacuation was performed.

Postoperatively, the patient's GCS improved to E1VtM2 with bilaterally nonreactive sluggish pupils. Over the next 48 hours, his neurological status improved to E2VtM4. Due to the need for prolonged ventilatory support, a percutaneous tracheostomy was performed. By POD 5, he showed further improvement with GCS E4VtM5. He was weaned from ventilatory support to CPAP, and subsequently to room air. At discharge, the patient was alert with GCS E4VtM5, bilaterally sluggishly reactive pupils, and was vitally stable.


 

 

Discussion

The prognostic implications of a GCS score of 3, especially when accompanied by BFDP, have traditionally been interpreted as nearly incompatible with survival. Nonetheless, several retrospective and observational studies over the last three decades have demonstrated that surgical intervention in this cohort is not universally futile, and a minority of patients may survive and achieve functional recovery.

Initial studies, including those by Jennett and Teasdale,[7] categorized GCS 3 with fixed pupils as indicative of irrecoverable brain damage, particularly due to presumed brainstem dysfunction or herniation. Fearnside et al[8] analyzed 308 severe TBI patients and found that none of the patients with bilateral fixed pupils and a GCS of 3 survived without profound disability.

Lieberman et al[9] studied 189 patients with GCS 3 and found a 13% survival rate, with 6% achieving a Glasgow Outcome Scale (GOS) score of 4 or higher. Shafi et al[10] reviewed 119 GCS 3 patients and reported 16% survival, with 10% returning to independent living. Hesdorffer et al[11] found that pupil reactivity and CT findings were better predictors of survival than GCS alone.

Coplin et al[12] analyzed 189 patients with fixed pupils. Among those with BFDP, a small proportion—especially those undergoing prompt surgical intervention—achieved a GOS of 4 to 5. Zhang et al[13] performed a retrospective review of 41 patients with GCS 3 and bilateral fixed pupils who underwent decompressive craniectomy. Remarkably, 7% survived with a favorable outcome (GOS ≥ 4). They emphasized that timing of surgery within 2 hours of herniation symptoms was critical. Bouras et al[14] and Papo et al[15] reported on 29 patients undergoing emergency surgery with GCS 3 and bilateral fixed pupils. Their findings demonstrated 17% survival, with 10% regaining functional independence, especially among younger patients without other systemic trauma. Papo et al even published a case series of 15 patients with GCS 3 and bilateral mydriasis. After emergency craniotomy, three survived with moderate disability, suggesting that aggressive surgical intervention may be warranted even in patients presumed unsalvageable.

Manley et al conducted one of the earliest meta-analyses, evaluating outcomes in severe TBI patients with GCS 3. While overall mortality was 88%, surgical decompression in a narrow time window was associated with better-than-expected survival rates, even among patients with fixed pupils.[16] Ganti et al conducted a pooled analysis involving 856 patients from 14 studies. While mortality remained high (81%), about 3 to 5% achieved independent functional recovery, particularly in cases with unilateral rather than bilateral fixed pupils, or where early surgical decompression was done.[17] Chibbaro et al published a focused meta-analysis of 10 studies on decompressive craniectomy in herniating patients with GCS 3. The pooled data indicated a 4.2% rate of good recovery (GOS 4–5), and 15.7% overall survival, especially in patients under 40 years of age and those without systemic injuries.[18]

A 2020 systematic review by Cooper et al reinforced that GCS 3 with fixed dilated pupils is not synonymous with brain death. They argued for individualized prognostication, integrating neuroimaging, pupillary reactivity, and cerebral perfusion studies before making withdrawal decisions.[19] The Brain Trauma Foundation[20] recommends delaying decisions about care withdrawal for at least 72 hours unless brain death criteria are met.


 

Conclusion

The accumulated evidence indicates that a GCS score of 3 with BFDP, while strongly associated with poor prognosis, is not uniformly fatal. Surgical intervention, particularly when done early, offers a chance of survival and even meaningful recovery in select patients, especially those who are young, without major extracranial trauma, and who present early. Prognostication should therefore be multifactorial and decisions regarding care limitations must be made with caution, ideally after an initial observation window.


 

 

Conflict of Interest

None declared.

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.



Address for correspondence

Deepak Agrawal, MBBS, MS, MCh
Department of Neurosurgery, All India Institute of Medical Sciences
New Delhi 110029
India   

Publication History

Article published online:
22 September 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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