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Case Reports
. 2017 Dec 30;9(12):e2004.
doi: 10.7759/cureus.2004.

Pitfall in Pupillometry: Exaggerated Ciliospinal Reflex in a Patient in Barbiturate Coma Mimicking a Nonreactive Pupil

Naresh Mullaguri  1 , Nakul Katyal  2 , Aarti Sarwal  3 , Jonathan M Beary  4 , Pravin George  1 , Naresh Karthikeyan  2 , Premkumar Nattanamai  2 , Christopher R Newey  1
Affiliations
Case Reports

Pitfall in Pupillometry: Exaggerated Ciliospinal Reflex in a Patient in Barbiturate Coma Mimicking a Nonreactive Pupil

Naresh Mullaguri et al. Cureus. .

Abstract

Although a neurological examination is fundamental to the evaluation of comatose patients, it is less reliable in a medically induced coma. A commonly misinterpreted finding in patients in a pentobarbital coma is altered pupillary reactivity secondary to an exaggerated ciliospinal reflex. Recognizing an exaggerated ciliospinal reflex in patients in a pentobarbital coma is important and may prevent unnecessary intervention. We present a patient induced in a pentobarbital coma for the treatment of status epilepticus who exhibited a nonreactive pupil secondary to an exaggerated ciliospinal reflex confirmed by pupillometry. We also discuss the anatomy of the ciliospinal reflex and literature regarding its clinical relevance.

Keywords: ciliospinal reflex; coma; pentobarbital; status epilepticus.

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Conflict of interest statement

Christopher R. Newey has served on speaker’s bureau for BARD medical. Drs. Mullaguri, Katyal, Sarwal, Beary, George, Karthikeyan, and Nattanmai have no relevant financial disclosures or conflicts of interests to report

Figures

Figure 1
Figure 1. Computed tomography (CT) of the head without contrast
CT showing bilateral posterior quadrant hypodensities consistent with vasogenic edema. These are typical radiological findings in posterior reversible encephalopathy syndrome (PRES).
Figure 2
Figure 2. Continuous electroencephalography (CEEG)
Bi-temporal montage on CEEG showing diffuse slowing with lateralized periodic discharges (LPDs) with over-riding beta activity in the left occipital region (A). Electrographic seizures evolving from the left posterior quadrant on CEEG (B).
Figure 3
Figure 3. Pupillary light reflex
A “nonreactive” left pupil to penlight stimulation (A). After 15 seconds of noxious stimulation to the ipsilateral cervical region, there is dilation of the pupil (B). This demonstrates an intact ciliospinal reflex. Penlight stimulation was then applied for 23 seconds, resulting in pupillary constriction (C).
Figure 4
Figure 4. Computed tomography (CT) of the head without contrast
There is hyperdensity within the bilateral posterior quadrants consistent with hemorrhagic transformation.
See this image and copyright information in PMC

References

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    1. The ciliospinal response in man. Reeves AG, Posner JB. https://www.ncbi.nlm.nih.gov/pubmed/5389693. Neurology. 1969;19:1145–1152. - PubMed
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    1. Suppression of brainstem reflexes in barbiturate coma. Grattan-Smith PJ, Butt W. http://adc.bmj.com/content/69/1/151. Arch Dis Child. 1993;69:151–152. - PMC - PubMed

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