Reversal of fixed pupils after spontaneous intraventricular hemorrhage with secondary acute hydrocephalus: report of two cases treated with early ventriculostomy.

Rapid reversal of fixed pupils, complete external 3rd nerve ophthalmoplegia, and coma occurred after early ventriculostomy in two hypertensive male patients with spontaneous intraventricular hemorrhage and secondary acute hydrocephalus. Putative pathophysiology of fixed pupils secondary to transtentorial herniation from obstructive hydrocephalus is discussed. Cases such as the present ones are unsettling because they are exceptions to the usually reliable negative prognosis indicated by fixed pupils. Nonetheless, it is important to report these cases to delineate which patients with this important clinical sign may benefit from aggressive management.