Reversal of Fixed Pupils after Spontaneous Intraventricular Hemorrhage with Secondary Acute Hydrocephalus: Report of two cases treated with early ventriculostomy
The development of fixed pupils in a comatose patient is such an ominous prognostic sign that its occurrence usually signifies a fatal outcome. However, in the 1970s a few reports appeared that documented recovery from fixed pupils resulting from both compressive and noncompressive lesions of the midbrain. The former group consisted primarily of a small number of patients with intracerebral hematomas secondary to ruptured cerebral aneurysms and postoperative and traumatic extradural and subdural hematomas who recovered after prompt neuropharmacological and neurosurgical intervention. The second group, without mass lesions and including less than a dozen cases, contained mainly patients who developed fixed pupils and coma after operations for intracranial aneurysms. Much more recently, Van Gijn et al. reported reversal of small nonreactive pupils within 1 to 2 days of early ventriculostomy in five patients with acute hydrocephalus secondary to aneurysmal subarachnoid hemorrhage (1985). We now describe an additional case of a middle-aged hypertensive man with spontaneous subarachnoid and intraventricular hemorrhage in whom rapid reversal of fixed pupils, complete external 3rd nerve opthalmoplegia, and coma occurred after ventriculoperitoneal shunting for secondary acute hydrocephalus. We further report a 71-year-old hypertensive man with spontaneous primary intraventricular hemorrhage in whom rapid reversal of fixed pupils, complete external 3rd nerve ophthalmoplegia, and coma occurred after ventricular drainage of secondary acute obstructive hydrocephalus.