BENIGN PRIMARY PONTINE HEMORRHAGE WITH CHEIRO-ORAL SYNDROME

Abstract

A patient with primary pontine hemorrhage showed cheiro-oral syndrome with only mild cerebellar and pyramidal signs. Serial CT scans showed a resolution of the hematoma and correlated with clinical improvement.A 54-year-old woman with a history of approximate ten years hypertension was hospitalized because of acute onset of mild unsteady gait and subjective paresthesia in the left face and left fingers two days before. General physical examination revealed a blood pressure of 150/112 mmHg and no arrhythmia. On neurological examination she was alert and good oriented without meningeal signs. The visual fields were intact to confrontation, and the pupils were normal in size bilaterally and briskly reactive. The eye movements were full and nystagmus was not observed. Facial weakness, hearing loss, dysarthria and dysphagia were not present. Motor examination revealed mild Barre's sign on the left hand. Deep tendon reflexes and muscle tone were normal, and Babinski's sign was not preset. Mild limb ataxia on the left sided extremities were present. Sensory examination revealed paresthesia on the left face, especially perioral and forehead areas, and the left fingers (cheiro-oral syndrome). Touch and pain senses were decreased on the same areas. CT scans (Figure 1) showed a high density area in the pons that was not enhanced after injection of contrast material. The increased density was mainly located in the right side, but extended to the opposite side as well as to the lower midbrain. There was no localized lesion in the cerebrum, thalamus and cerebellum.A CT scan obtained after two weeks showed a resolution of the high density. Limb ataxia and Barre's sign disappeared nearly within one week, and she could walk well on tandem gait. The paresthesia on the left face and fingers decreased gradually.The lesion of our case was illustrated in Figure 2 at the pontine level. The lesion might include some parts of pontocerebellar tract, corticospinal tract and right medial lemniscus. We consider the lesion of the some parts of right medial lemniscus is responsible for the contralateral cheiro-oral syndrome in this case.