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.
