J Neurocrit Care.  2022 Dec;15(2):136-140. 10.18700/jnc.220066.

Fixed and dilated pupils by pupillometer in lateralized periodic discharges: a case report in the neurocritical care unit

• Primiani CT
• Husari KS
• Mathur R
• Geocadin RG

• KMID: 2538772
• DOI: http://doi.org/10.18700/jnc.220066

Abstract

Background
Fixed and dilated pupils (FDPs) have become synonymous with devastating neurological damage and brainstem injury commonly associated with mass effect and herniation. Infrequently, changes in pupillary light response have been described with seizures; however, the loss of pupillary response with documented Neurological Pupil index has not been well established in patients with seizures.
Case Report
We present a case report describing a middle-aged female patient with focal status epilepticus with intermittent FDPs. An abnormal pupillary response occurred with right hemispheric lateralized periodic discharges and resolution with anti-seizure medication escalation. To our knowledge, this is the first description of objective documentation of reversible FDP as a possible clinical correlate of lateralized periodic discharges.
Conclusion
The use of handheld automated pupillometry in conjunction with electroencephalogram (EEG) has provided the therapeutic direction. Further research is warranted to fully describe the mechanistic underpinnings of these observations.

Keyword

Seizure; Epilepsy; Eye; Pupils; Autonomic; Critical

Figure

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  Fig. 1. Computed tomography perfusion imaging. (A) Mean transit time (MTT), (B) cerebral blood flow (CBF), (C) cerebral blood volume (CBV), consistent with hyper-perfusion in the right temporal and occipital lobes (arrows).

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  Fig. 2. Screenshot of a 10-second clip of an electroencephalogram in bipolar montage displaying, (A) continuous right hemispheric lateralized periodic discharges with sharp wave morphology, occurring at approximately 0.7–0.8 Hz, noted by an arrow and asterisk, coinciding with fixed and dilated pupil (FDP). (B) Ten-second clip of an electroencephalogram following the administration of a 5-mg midazolam bolus with appearing transient improvement of lateralized periodic discharges and resolution of FDP.

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