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Hypertensive Pontine Hemorrhage

Contents

  1. Case Report
  2. Introduction
  3. Signs and symptoms
  4. Pathophysiology
  5. Diagnosis
  6. Treatment
  7. Hypertensive Pontine Hemorrhage Video

Case Report


  • 52yr old male
  • k/c/o HTN not on regular medication
  • Presented with sudden onset loss of consciousness


On Examination


  • GCS - E1VetM1
  • Pupils -B/L 1mm NRTL (Pin-Point Pupils)
  • Planters B/L mute


CT Scan
Hypertensive Pontine Hemorrhage CT Scan
Hypertensive Pontine Hemorrhage


  • Seen in long standing poorly-controlled chronic hypertension. 
  • It carries a very poor prognosis.
  • Pontine hemorrhage accounts for 5-10% of all hemorrhagic strokes (Jang et al 2011)


Signs and symptoms

  • "classic" pontine hematoma syndrome characterized by coma, quadriparesis, and eventual demise (Kushner et al 1985)
  • Clinical features of Pontine Hematoma are (Deng and Gaillard et al.)
    • Loss of consciousness (most common)
    • long tract signs including tetraparesis
    • cranial nerve palsies
    • seizures
    • Cheyne-Stokes respiration
  • CST does not play an essential role in recovery of independent walking and vestibulospinal tracts may not crucially affect recovery of independent walking in patients with pontine hemorrhage. In contrast, and intact CRP (corticoreticular pathway) or changes of the CRP integrity appear to be related to the recovery of gait function (Yeo et al 2020)

Pathophysiology

Hypertensive Pontine Hemorrhage
  • Due to rupture of penetrating arteries from the basilar artery extending into the pons 
  • These arteries are prone to lipohyalinosis as a result of poorly-controlled hypertension 
  • This makes the vessel wall prone to rupture. 
  • Larger paramedian perforators are more commonly the culprit vessels
Other Causes of Pontine Hemorrhage
Other causes of pontine hemorrhage include
  • Cavernoma
  • AV Malformation
  • Tumour bleed
  • Transtentorial herniation (Duret Hemorrhage)


Diagnosis

NCCT Brain is the investigation of choice. It shows:
  • Acute intraparenchymal hemorrhage within the pons
  • The hematoma frequently ruptures into the 4th ventricle 

Treatment

  • Poor prognosis
  • Large bleeds are almost universally fatal. 
  • Open surgical evacuation of the clot is usually not performed
  • In smaller hemorrhages, medical management and treatment of hydrocephalus with extraventricular drains may be life saving, 
  • Mortality ranges between 30% and 90% (Jang et al 2011)
  • Outcome depends on the volume of the bleed and initial GCS


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