The localizing value of asymmetry in pupillary size in severe head injury: relation to lesion type and location

Neurosurgery. 1994 May;34(5):840-5; discussion 845-6. doi: 10.1227/00006123-199405000-00008.


Reliable Assessment of the probability that a head injury patient harbors a surgical intracranial lesion is critical to both triage and treatment. The authors analyzed data from 608 patients with severe head injuries (Glasgow Coma Scale score, < or = 8) in the Traumatic Coma Data Bank to assess the reliability of pupillary asymmetry in predicting the presence and location of an intracranial mass lesion. Of 210 patients with pupillary asymmetry of > or = 1 mm, 63 (30%) had intracranial mass lesions, 52 (25%) of which were extra-axial in location, 38 (73%) of these located ipsilateral to the larger pupil. Of 51 patients with asymmetry of > or = 3 mm, 22 (43%) had intracranial mass lesions, 18 (35%) of which were extra-axial in location, 14 (64%) of these located ipsilateral to the larger pupil. For both asymmetry categories, strong interactions were found with age and mechanism of injury, the highest incidence of extra-axial lesions occurring in older patients injured other than as occupants of motor vehicles. The authors developed regression equations that provide a graphic means to predict the presence of an intracranial hematoma using data on pupillary asymmetry, age, and mechanism of injury. This predictive model, interpreted in a hospital- and patient-specific fashion, should be of significant use in directing triage, activating diagnostic and therapeutic resources, and evaluating the utility of exploratory trephination.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Accidents, Traffic
  • Anisocoria / diagnosis
  • Anisocoria / physiopathology*
  • Anisocoria / surgery
  • Brain Injuries / diagnosis
  • Brain Injuries / physiopathology*
  • Brain Injuries / surgery
  • Brain Mapping / methods*
  • Cerebral Hemorrhage / diagnosis
  • Cerebral Hemorrhage / physiopathology*
  • Cerebral Hemorrhage / surgery
  • Dominance, Cerebral / physiology*
  • Glasgow Coma Scale
  • Head Injuries, Closed / diagnosis
  • Head Injuries, Closed / physiopathology
  • Head Injuries, Closed / surgery
  • Humans
  • Neurologic Examination / methods*
  • Neurologic Examination / statistics & numerical data
  • Predictive Value of Tests
  • Probability
  • Prospective Studies
  • Reflex, Pupillary / physiology*
  • Risk Factors
  • Tomography, X-Ray Computed