Skip to main content


Log in

Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils. A cohort study

  • Original Article - Brain Injury
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript



The outcome of patients with severe traumatic brain injury (TBI) and acute traumatic subdural hematoma (aSDH) admitted to the emergency room with bilaterally dilated, unreactive pupils (bilateral mydriasis) is notoriously poor.


Of 2074 TBI patients consecutively admitted to our facility between 1997 and 2012, 115 had a first CT scan with aSDH, unreactive bilateral mydriasis, and a Glasgow Coma Score of 3 or 4. Sixty-two patients were unoperated and died within hours or a few days. The remaining 53 patients (2.5% of the 2074 consecutive patients) were scheduled for emergent evacuation of the aSDH. We compared three different dosages of mannitol to landmark different comprehensive levels of treatment: (1) a “basic” level of treatment characterized by a single conventional dose (18 to 36 g), (2) “reinforced” treatment landmarked by a single high dose (54 to 72 g), and (3) “aggressive” treatment landmarked by a single high dose (90 to 106 g). Doses above 36 g were administered intravenously over a period of 5 min.


Of the 53 selected patients, 7 were aggressively managed (13.2%) and 24 (45.3%) received reinforced treatment. Rates of hyperventilation and barbiturate bolus administration were appropriately associated with increasing doses of mannitol. After adjustment for age, aggressive management was significantly associated with a lower risk of death and persistent vegetative state [adjusted OR 0.016 (95% 0.001–0.405)]. Patients surviving after aggressive management suffered more severe disability at 1 year.


The study shows an association between reduced mortality and persistent vegetative state, albeit at the cost of increased long-term severe disability in survivors, and aggressive medical preoperative management of mydriatic patients with aSDH following TBI.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others


  1. Chamoun RB, Robertson CS, Gopinath SP (2009) Outcome in patients with blunt head trauma and a Glasgow coma scale score of 3 at presentation. J Neurosurg 111:683–687. doi:10.3171/2009.2.JNS08817

    Article  PubMed  PubMed Central  Google Scholar 

  2. Chaudhuri K, Malham GM, Rosenfeld JV (2009) Survival of trauma patients with coma and bilateral fixed dilated pupils. Injury 40:28–32. doi:10.1016/j.injury.2008.09.004

    Article  PubMed  Google Scholar 

  3. Chieregato A, Paci G, Portolani L, Ravaldini M, Fabbri C, Martino C, Russo E, Simini B (2014) Satisfaction of patients’ next of kin in a ‘Hub & Spoke’ ICU network. Anaesthesia 69(10):1117–1126. doi:10.1111/anae.12806

    Article  CAS  PubMed  Google Scholar 

  4. Chieregato A, Tanfani A, Compagnone C, Turrini C, Sarpieri F, Ravaldini M, Targa L, Fainardi E (2007) Global cerebral blood flow and CPP after severe head injury: a xenon-CT study. Intensive Care Med 33:856–862

    Article  PubMed  Google Scholar 

  5. Clusmann H, Schaller C, Schramm J (2001) Fixed and dilated pupils after trauma, stroke, and previous intracranial surgery: management and outcome. J Neurol Neurosurg Psychiatry 71:175–181

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ, RESCUEicp Trial Collaborators (2016) Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 375:1119–1130. doi:10.1056/NEJMoa1605215

    Article  PubMed  Google Scholar 

  7. Jennett B, Bond M (1975) Assessment of outcome after severe brain damage. Lancet 1(7905):480–484

    Article  CAS  PubMed  Google Scholar 

  8. Marshall LF, Smith RW, Rauscher LA, Shapiro HM (1978) Mannitol dose requirements in brain-injured patients. J Neurosurg 48:169–172

    Article  CAS  PubMed  Google Scholar 

  9. Meyer A (1920) Herniation of the brain. Arch Neur Psych 4:387–400. doi:10.1001/archneurpsyc.1920.02180220036003

    Article  Google Scholar 

  10. Muizelaar JP, Wei EP, Kontos HA, Becker DP (1983) Mannitol causes compensatory cerebral vasoconstriction and vasodilation in response to blood viscosity changes. J Neurosurg 59:822–828

    Article  CAS  PubMed  Google Scholar 

  11. Murray GD, Barer D, Choi S, Fernandes H, Gregson B, Lees KR, Maas AI, Marmarou A, Mendelow AD, Steyerberg EW, Taylor GS, Teasdale GM, Weir CJ (2005) Design and analysis of phase III trials with ordered outcome scales: the concept of the sliding dichotomy. J Neurotrauma 22:511–517 Review

    Article  PubMed  Google Scholar 

  12. Osler T, Baker SP, Long W (1977) A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma 43:922–925 discussion 925-6

    Article  Google Scholar 

  13. Poole D (2017) Small observational studies and data sharing: fuel for debate and coins for the piggy bank of evidence. Intensive Care Med. doi:10.1007/s00134-017-4696-1

    Google Scholar 

  14. Saatman KE, Duhaime AC, Bullock R, Maas AI, Valadka A, Manley GT (2008) Workshop scientific team and advisory panel members. Classification of traumatic brain injury for targeted therapies. J Neurotrauma 25:719–738

    Article  PubMed  PubMed Central  Google Scholar 

  15. Sakas DE, Bullock MR, Teasdale GM (1995) One-year outcome following craniotomy for traumatic hematoma in patients with fixed dilated pupils. J Neurosurg 82:961–965

    Article  CAS  PubMed  Google Scholar 

  16. Schrot RJ, Muizelaar JP (2002) Mannitol in acute traumatic brain injury. Lancet 359:1633–1634 Review

    Article  PubMed  Google Scholar 

  17. Scotter J, Hendrickson S, Marcus HJ, Wilson MH (2015) Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emerg Med J 32:654–659. doi:10.1136/emermed-2014-204260 Review

    Article  PubMed  Google Scholar 

  18. Servadei F, Antonelli V, Betti L, Chieregato A, Fainardi E, Gardini E, Giuliani G, Salizzato L, Kraus JF (2002) Regional brain injury epidemiology as the basis for planning brain injury treatment. The Romagna (Italy) experience. J Neurosurg Sci 46:111–119

    CAS  PubMed  Google Scholar 

  19. Shapiro HM, Galindo A, Wyte SR, Harris AB (1973) Rapid intraoperative reduction of intracranial pressure with thiopentone. Br J Anaesth 45:1057–1062

    Article  CAS  PubMed  Google Scholar 

  20. Skoglund TS, Nellgård B (2005) Long-time outcome after transient transtentorial herniation in patients with traumatic brain injury. Acta Anaesthesiol Scand 49:337–340

    Article  CAS  PubMed  Google Scholar 

  21. Sousa J, Sharma RR, Pawar SJ, Mahapatra A, Lad SD (2002) Long term outcome in patients with severe head injury and bilateral fixed dilated pupils. Neurol India 50:430–435

    CAS  PubMed  Google Scholar 

  22. Stocchetti N, Maas AI, Chieregato A, van der Plas AA (2005) Hyperventilation in head injury: a review. Chest 127:1812–1827 Review

    Article  PubMed  Google Scholar 

  23. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84

    Article  CAS  PubMed  Google Scholar 

  24. Tien HC, Cunha JR, Wu SN, Chughtai T, Tremblay LN, Brenneman FD, Rizoli SB (2006) Do trauma patients with a Glasgow coma scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma 60:274–278

    Article  PubMed  Google Scholar 

  25. Verweij BH, Muizelaar JP, Vinas FC (2001) Hyperacute measurement of intracranial pressure, cerebral perfusion pressure, jugular venous oxygen saturation, and laser Doppler flowmetry, before and during removal of traumatic acute subdural hematoma. J Neurosurg 95:569–572

    Article  CAS  PubMed  Google Scholar 

  26. Videen TO, Zazulia AR, Manno EM, Derdeyn CP, Adams RE, Diringer MN, Powers WJ (2001) Mannitol bolus preferentially shrinks non-infarcted brain in patients with ischemic stroke. Neurology 57:2120–2122

    Article  CAS  PubMed  Google Scholar 

  27. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370:1453–1457

    Article  Google Scholar 

  28. Wise BL (2004) High-dose mannitol. J Neurosurg 101:566–567 author reply 568

    PubMed  Google Scholar 

Download references


We are grateful to Maurizio Ravaldini (RN) (Unità Operativa Anestesia e Rianimazione, Rianimazione per la Traumatologia e le Neuroscienze, Ospedale Bufalini, AUSL Romagna, Cesena, Italy) for daily assistance and development of our local TBI patient database.

We also are grateful to Laila Portolani (Head Nurse), Giulia Paci (RN), Wilma Benedettini (RN), Diletta Castagnoli (RN), Silvia Chiesa (RN), Veruska Pransani (RN), and Sara Salvigni (RN) (Unità Operativa Anestesia e Rianimazione, Rianimazione per la Traumatologia e le Neuroscienze, Ospedale Bufalini, AUSL Romagna, Cesena, Italy) for collecting patient outcomes at 1 year.

We are also grateful to Erika Cordella (MD), Silvia Olivieri (MD), and Giuseppe Sabia (MD) (Unità Operativa Anestesia e Rianimazione, Rianimazione per la Traumatologia e le Neuroscienze, Ospedale Bufalini, AUSL Romagna, Cesena, Italy) who participated in prospective data collection for the local trauma registry.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Arturo Chieregato.

Ethics declarations


No funding was received for this research.

Conflicts of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Formal consent

For this type of study formal consent is not required.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chieregato, A., Venditto, A., Russo, E. et al. Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils. A cohort study. Acta Neurochir 159, 1553–1559 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: