While FDP without deterioration of consciousness has been described due to traumatic subdural and epidural hematomas, we report this unusual constellation as a sign of rising ICP and impeding herniation due to intraparenchymal contusions, highlighting that any pupillary change warrants prompt work-up and intervention.Ĭase report contusion fixed pupil intraparenchymal hemorrhage traumatic brain injury. His pupil became reactive 5 hours after surgery. We performed an emergent right-sided decompressive hemicraniectomy with durotomy and duraplasty. Head computed tomography showed worsening midline shift and interval increase in subfalcine herniation related to increased peri-hematoma edema. Hypertonic saline and mannitol produced no improvement in his pupillary exam. Corneal reflexes were intact bilaterally. His gaze was dysconjugate with impaired vertical excursion and inability to fully abduct to the right side. He described complete loss of vision and could not identify objects or count fingers. The patient was drowsy, arousable to tactile stimuli, answering questions, oriented to place and time, following commands on his right side, maintaining Glasgow Coma Scale of 14 (E4, V5, M6). On hospital day 8, his right pupil became fixed (NPi 0) and dilated (4.8 mm). A 58-year-old man with history of hypertension and diabetes mellitus type II presented after being assaulted, with bifrontal contusions and right frontal intraparenchymal hemorrhage. We describe an exceptional case of a patient with bifrontal contusions who developed worsening edema and a unilaterally FDP while maintaining consciousness and the ability to communicate. Although angle closure in all its forms is vision threatening, early diagnosis and appropriate management can stabilize disease and minimize vision loss. Patients with fixed and dilated pupils (FDPs) due to rising intracranial pressure (ICP) typically experience a deterioration in consciousness. The mainstays of therapy are medications that lower intraocular pressure and laser peripheral iridotomy for any component of pupillary block.
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