A patient with TBI has preserved pupillary reactivity on exam. This finding is most consistent with which prognosis?

• A. Potentially worse prognosis.
• B. Potentially better prognosis.
• C. No prognostic significance.
• D. Immediate need for surgery.

Answer: (B)

Preserved pupillary reactivity means the brainstem pathways controlling the pupil light reflex are functioning. In traumatic brain injury, a reactive pupil suggests the midbrain and oculomotor pathways are intact, which is associated with a higher likelihood of recovery and a better overall prognosis. Nonreactive or fixed pupils, by contrast, can indicate brainstem compromise or impending herniation and are linked to poorer outcomes. So, this finding points toward a potentially better prognosis. It doesn’t by itself determine need for surgery, which depends on imaging and mass effect, but reactive pupils are a favorable sign amid the overall clinical picture.