Introduction:
In the intensive care unit (ICU), acute-onset anisocoria is typically considered a sign of intracranial pathology with increased intracranial pressure (ICP), often resulting in third cranial nerve compression and necessitating urgent intervention. However, alternative etiologies such as elevated intra-abdominal pressure (IAP) in severe acute pancreatitis (SAP) can also precipitate increased ICP and anisocoria.

Aim:
This report aims to examine the association between elevated IAP and the development of acute anisocoria with increased ICP in SAP patients and to evaluate the impact of early cerebroprotective measures on patient outcomes.

Case study:
Three SAP patients in the ICU presented with sudden anisocoria. Despite initial concerns for central nervous system pathology, brain computed tomography (CT) scans were normal. Early cerebroprotective strategies were initiated in all cases. Two patients experienced complete resolution of anisocoria and stabilization of ICP, whereas one patient unfortunately succumbed to complications.

Results and discussion:
These cases highlight that increased IAP can indirectly elevate ICP, manifesting as anisocoria in critically ill SAP patients. Clinicians should consider non-CNS etiologies when evaluating anisocoria, particularly when imaging findings are unremarkable. Non-invasive diagnostic tools, such as optic nerve sheath diameter measurement, may aid in the early detection of raised ICP and guide timely intervention.

Conclusions:
Recognizing elevated IAP as a potential contributor to increased ICP and anisocoria is crucial for managing SAP patients. Early cerebroprotective interventions and timely intervention to lower IAP can improve outcomes, yet further research is needed to establish definitive IAP thresholds and optimize therapeutic strategies.