Primary Pontine Hemorrhage Research Articles

Predictors of Surgical Results in Patients with Primary Pontine Hemorrhage.

Prediction of outcome for surgical patients with primary pontine hemorrhage (PPH) is seldom reported although many predictors from clinical and radiological features have been identified in conservative patients. The purpose of this study was to assess the prognostic factors affecting the 30-day mortality and 3-month functional outcome in surgical patients after PPH. Forty-five patients with large PPH ( > 5 ml) and Glasgow Coma Scale (GCS) score < 8 were treated surgically at West China Hospital. The demographic, clinical, imaging and follow-up data were collected retrospectively. Factors affecting the mortality and functional outcome were statistically analyzed. Fourteen patients (31.1%) died within 30 days and 7 patients (15.6%) gained a favorable functional recovery within 3 months. A multivariate analysis showed that the hematoma volume, GCS score on admission, age, and type of hemorrhage were all significantly related to the 30-day mortality, while the hematoma volume, GCS score on admission, rostrocaudal extension were associated with the 3-month functional outcome. The presence of hydrocephalus was not found responsible for the surgical outcomes. The identification of these prognostic factors is helpful for selecting the candidates for surgical treatment. Those with younger age, smaller hematoma without rostrocaudal extension, unilateral hemorrhage, and higher GCS score may benefit from surgery.

Minimally Invasive, but Not at the Cost of Maximally Effective, in the Surgical Removal of Brainstem Cavernous Malformations

Impending respiratory failure is catastrophic neurological deterioration caused by repeated c of a brainstem cavernous malformation (BSCM). The benefit and outcome prediction of acute surgery for this fatal condition is rarely reported. In this study, the authors reported a case series of acute surgical treatment (≤3 weeks after the last hemorrhagic episode) for the BSCM with impending respiratory failure and reviewed literature over the past 20 years.Clinical and outcome data from 6 consecutive acute surgically-treated BSCM patients were analyzed. Intracerebral hemorrhage (ICH) scores, primary pontine hemorrhage (PPH) scores, and Lawton's BSCM grading were applied for surgical outcome prediction. Ten related articles were included for the literature review.There were three men and three women, with a mean age of 32.2 ± 9.3 years (range 15–45 years). The BSCMs were located at the pons in 5 cases and the medulla in 1 case. The ICH score was 1–2 in all cases, while the PPH score was 0 in all pontine BSCMs. For Lawton's BSCM grading, 3 cases were grade 2, 2 cases were grade 3, and 1 case was grade 1. All patients achieved spontaneous respiratory dysfunction relief postoperatively and significantly improved at follow-up (mean 4.47 ± 0.24 years;range4.0–5.6 years).Repeated hemorrhagic BSCM with impending respiratory failure can benefit from acute surgical treatment. The ICH score, PPH score, and Lawton's BSCM grading are promisingly useful tools for fast and efficient surgical outcome prediction.

Risk factors analysis of outcomes for patients with primary pontine hemorrhage

To evaluate the risk factors of prognosis in patients with primary pontine hemorrhage. A retrospective analysis was conducted using data from 60 patients admitted with a diagnosis of primary pontine hemorrhage to the Department of Neurology of Nanfang Hospital in Guangzhou City. Patients were classified as survivors (n=34) and non-survivors (n=26) according to their outcomes on 30 days from the onset of symptoms. Univariate analysis and multivariate logistic regression analysis were performed on clinical data and imaging features of patients. Receiver operating characteristic curve (ROC curve) analysis was used on continuous parameters verified by multivariate logistic regression analysis to determine their cut-off value. The 30-day mortality was 43.3% for 60 patients with primary pontine hemorrhage. Univariate analysis showed Glasgow coma scale (GCS) at admission, temperature, heart rate, hemorrhage volume, mechanical ventilation, involvement of ventricles and location of hematoma were statistically related to 30-day mortality in patients with primary pontine hemorrhage. Multivariate logistic regression analysis demonstrated that the GCS at admission [odds ratio (OR)=0.745, 95% confidence interval (95%CI) 0.585 to 0.949], hemorrhage volume (OR=1.438, 95%CI 1.077 to 1.919) and location of hematoma (basal-tegmental hemorrhage, OR=0.120, 95%CI 0.016 to 0.904) were independent risk factors of poor prognosis in patients with primary pontine hemorrhage (all P<0.05). ROC curve analysis showed the cut-off value for GCS score at admission and hemorrhage volume was 7.5 and 5.5 ml, respectively. Patients suffering from primary pontine hemorrhage in the basal-tegmental region, GCS<7.5 at admission and hemorrhage volume≥5.5 ml would lead to a poor outcome in 30 days.

The prediction of 30‐day mortality in patients with primary pontine hemorrhage: a scoring system comparison

Owing to its low morbidity but high mortality, no accurate scoring system focuses on primary pontine hemorrhage (PPH) has been established. We aim to compare the performances of the Acute Physiology and Chronic Health Evaluation (APACHE) II and the Simplified Acute Physiology Score (SAPS) II with the ICH score in predicting the 30-day mortality in patients with PPH. We conducted a retrospective analysis of patients admitted with a diagnosis of PPH to a university-affiliated hospital in southern China from May 2000 to June 2011. Data related to patient demographics and that necessary to calculate APACHE II, SAPS II, and ICH score were recorded. Performances of these scoring systems were presented as calibration and discrimination, which were measured by the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating characteristic (ROC) curve, respectively. Among 75 patients with PPH finally included, 31 (41.3%) died within 30 days. SAPS II (χ(2) = 6.57, P = 0.682) had the best calibration, followed by APACHE II (χ(2) = 8.06, P = 0.428) and ICH score (χ(2) = 4.94, P = 0.176). Furthermore, in terms of area under the ROC curve, APACHE II (0.919) was more discriminative than SAPS II (0.890) and ICH score (0.844). In predicting 30-day mortality in patients with PPH, SAPS II has the best calibration, while APACHE II has the highest discrimination. The ICH score, which is easier and simpler to calculate, should be modified for PPH.

Predictors of 30-day Mortality and 90-day Functional Recovery after Primary Pontine Hemorrhage

The factors related to death and functional recovery after primary pontine hemorrhage (PPH) in Koreans has not been well defined. The authors sought to identify independent predictors of death and functional recovery after PPH using data obtained at a single institute. Data were collected retrospectively on 281 patients with PPH admitted to the Stroke Unit at our hospital between January 1, 2000 and December 31, 2009. Multivariate logistic regression analysis was used to evaluate the associations between selected variables and 30-day mortality and 90-day functional recovery after PPH. One-hundred and ten patients (39.1%) died within 30 days of PPH and 27 patients (9.6%) achieved functional recovery within 90 days. By multivariate analysis, unconsciousness, dilated pupils, abnormal respiration, systolic blood pressure < 100 mmHg, hydrocephalus, and conservative treatment were found to be predictors of 30-day mortality, whereas consciousness, intact motor function, no history of hypertension or diabetes mellitus, intact eye movement, a hematoma volume of < 5 mL, no ventricular hemorrhage, and normally sized ventricle were found to be predictors of 90-day functional recovery. The present findings suggest that systolic hypotension of less than 100 mmHg may predict 30-day mortality and a history of underlying hypertension and diabetes mellitus may predict 90-day functional recovery.

PO20-WE-02 Eye movement abnormalities in patients with primary pontine haemorrhage

PO20-WE-02 Eye movement abnormalities in patients with primary pontine haemorrhage

Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage

Background and purpose Primary pontine hemorrhage (PPH) accounts aproximately for about 5–10% of intracranial hemorrhages, and PPHs are known to have a much less uniform prognosis. We aimed to evaluate the clinical and radiological predictors affecting the mortality in 32 patients with PPH. Material and methods We retrospectively evaluated the data of 32 patients with PPH admitted to our clinic between 1994 and 2004. We divided the patients into two groups: (1) patients who survived (14 patients), and (2) patients who died (18 patients). The two groups were compared for age, gender, diabetes mellitus, hypertension, initial clinical status, initial GCS, pupillary abnormalities, ophthalmoparesis, volume and localisation of hemorrhage, intraventricular and extrapontine extension, necessity of mechanical ventilation and hydrocephalus. The hematoma volumes were measured with the formulation described by Broderick. Results Eighteen patients (56%) died and 14 patients (44%) survived. The patients who died (61.3 ± 8.8) were older than the survivors (56.4 ± 11.0), but the difference was not statistically significant. The mean GCS was 4.4 ± 0.2, the mean hematoma volume was 9.9 ± 3.3 ml for patients who died and the mean GCS was 10.1 ± 3.3, the mean hematoma volume was 3.3 ± 1.2 ml for survivors ( p < 0.001). Coma on admission ( p = 0.001), extrapontine extension ( p = 0.001), intraventricular extension ( p = 0.019), necessity of mechanical ventilation ( p = 0.007), hydrocephalus ( p = 0.024), massive and bilateral tegmental localisation ( p = 0.006) were found statistically significant predictors for mortality with univariate comparison, and coma on admission ( p = 0.038) was the only significant predictor with multivariate regression analysis. Conclusion In patients with PPH, it is important to know the prognostic factors for mortality for planning the treatment protocol, and coma and bad clinical status on admission was found the only significant prognostic predictor for mortality with multivariate regression analysis.

Cause Is the Main Predictor of Outcome in Patients with Pontine Hemorrhage

Background: Pontine hemorrhages frequently lead to death or severe disability. Predictors of early mortality have been previously described but little is known about the factors influencing long-term disability. Objective: Determine clinical predictors of long-term outcome in a large hospital series of patients with acute pontine hemorrhage. Methods: Review of all patients with acute pontine hemorrhage admitted to a single tertiary center from 1990 to 2002 who underwent a diagnostic workup including brain magnetic resonance imaging (MRI). Long-term outcome was rated using the modified Rankin Scale (mRS) score at the time of the last follow-up. Odds ratios (ORs) for predictive factors were calculated using univariate and multivariable logistic regression analysis. Level of significance was established at p < 0.01. Results: We identified 44 consecutive patients with acute pontine hemorrhage. Twenty-four patients had primary hemorrhages (no cause other than hypertension). Arteriovenous or cavernous malformations were documented by brain MRI in 20 patients. Patients with primary hemorrhages had worse Glasgow Coma Scale sum scores (p = 0.01) and more unfavorable CT patterns (p = 0.005) at presentation. Eighteen percent of the patients died in the hospital. Mean follow-up among survivors was 20 months (range 3–144 months). Twenty-two percent of the patients remained severely disabled (mRS greater than 2) at 3 months and at the time of the last follow-up. All deaths occurred in patients with primary pontine hemorrhage. Poor outcome (death or severe disability) was more frequent in patients with primary hemorrhages when compared with patients harboring cavernous malformations (62 versus 5%; p < 0.01). Primary hemorrhage was the only independent predictor of poor outcome in multivariable regression analysis (OR 12; p = 0.029). Conclusions: Cause is a main predictor of clinical and radiological severity at presentation and outcome in patients with pontine hemorrhage. The first episode of hemorrhage in patients with brainstem cavernous malformations is usually benign. Pontine hemorrhage associated with prior hypertension is much more devastating.

Medial Pontine Hemorrhagic Stroke

This case report documents a rare opportunity to observe the motor function of an individual for nearly 6 months following a primary pontine hemorrhage in the medial pontine tegmentum of the brain stem. The purpose of this report is to illustrate how knowledge of the location of the hemorrhage, in conjunction with knowledge of brain-stem structure-function relationships, informs physical therapist examination and intervention. RM, a right-handed 81-year-old man with hypertension, had a hemorrhagic brain-stem stroke that severely compromised control of posture and whole-limb movements. Some residual ability to use the right hand and fingers remained, provided the trunk and right upper arm were stabilized. RM had undiminished intellectual abilities and unaltered memory because of sparing of cerebral cortices. RM's cognitive abilities, however, were obscured by severe impairments in interpersonal communication because of extensive damage to cranial nerve structures. Computed tomographic scans verified that the hematoma crossed the midline and was confined to the medial pontine tegmentum. We interpret motor deficits resulting from stoke in the medial pontine tegmentum in terms of damage to brain-stem descending motor systems and ascending somatosensory systems. Recognition of cognitive and residual motor abilities following brain-stem stroke can aid in the development of rehabilitation strategies.

Bilateral Horizontal Gaze Palsy Caused by a Primary Pontine Hemorrhage in an Alert Patient

Bilateral horizontal gaze palsies are rare, and we are aware of only 1 previously reported case that was due to a primary pontine hemorrhage (PPH). We report a 2nd patient with a primary pontine tegme

Primary pontine hemorrhage: a new CT classification.

The prognosis of primary pontine hemorrhage depends on the size, location, and extent of the hematoma. We investigated the relationship between CT features and prognosis in 61 consecutive cases. The CT features were classified into four types: basal-tegmental (23 cases), bilateral tegmental (7), massive (14), and small unilateral tegmental (17). Case survival rate was 94.1% for the small unilateral tegmental type, 26.1% for the basal-tegmental type, 14.3% for the bilateral tegmental type, and 7.1% for the massive type.

原発性橋出血の生命予後 超急性期における血腫量および血腫進展方向からの検討

原発性橋出血の生命予後 超急性期における血腫量および血腫進展方向からの検討

Primary pontine hemorrhage: Clinico-computed tomographic correlations

A series of 10 patients with primary pontine hemorrhage with CT confirmation is reported. All patients were hypertensive. Seven patients had classical pontine hematoma syndrome characterized by decreasing levels of consciousness, quadriparesis, and eventual demise. The three other patients had atypical or partial clinical features of pontine hemorrhage and good prognosis. The pontine hemorrhage can be divided into 4 groups from the viewpoint of location of the hematomas. There are bilateral tegmentobasis (massive) type, hemipontine type, localized tegmentum type, and localized basis type. There was no evidence of ventricular extension in all 10 cases. All patients suffering the massive type had classical pontine hematoma syndrome and fatal outcome, the other three remaining types had atypical or partial clinical features for pontine hemorrhage and survived. It is concluded that CT is highly reliable method for the diagnosis and location of primary pontine hemorrhage.

Primary pontine haemorrhage: clinical and computed tomographic correlations.

The clinical and computerised tomographic findings in 40 patients with primary pontine haemorrhage were reviewed. Twenty-nine patients were hypertensive. Four patients had angiographic or necropsy evidence of vascular malformations. In 33 cases, there was rapid deterioration to maximal neurological deficit; whereas in seven cases, there was sudden onset but subsequent progression to maximal deficit 24 hours to 5 days following the initial ictus. Seven patients had clinical features considered atypical for pontine haemorrhage. Five patients survived and four of these were capable of performing activities of daily living within 3 months of the haemorrhage. In all cases CT showed a hyperdense non-enhancing brain stem haematoma. There was evidence of ventricular extension in 27 cases. There was CT evidence of subarachnoid blood in only two patients who also had vascular malformations. In 26 cases, there was CT evidence that the haematoma extended to the midbrain and in four cases to the thalamic region. In six cases CT was repeated 6 to 21 days after the initial scan and it showed resolution of the haematoma in size and density; none of the haematomas showed post-contrast enhancement on initial or follow-up CT.

Successful Evacuation of a Pontine Hematoma in Chronic Stage

A 52-year-old male was brought to Wakakusa Daiichi Hospital by ambulance because he had fallen unconscious. On admission he was stuporous. Neurological examination revealed left-sided facial palsy, left-sided ptosis, right-sided hemiplegia, and marked impairment of horizontal eye movement except for convergence. Computed tomography (CT) revealed a small high density area in the paramedian tegmentum. Cerebral angiography showed no abnormal vessels. Three hours after admission he became alert. One month after admission the right-sided hemiplegia improved, but he could not walk by himself. CT performed 45 days after admission showed a low density area in the pontine tegmentum with the fourth ventricle compressed persistently. Fifty days after admission, suboccipital craniectomy and evacuation of the hematoma was performed. The postoperative course was uneventful. One week after surgery the bulbar palsy improved and the tracheotomy could be closed. One month later, facial palsy and hemiplegia had so improved that he could close his eyes and walk without aids. Half a year after evacuation of the hematoma, the patient recovered to partially assisted daily life. Cases of primary pontine hemorrhage successfully evacuated have been reported, but the majority of primary pontine hemorrhages are treated conservatively. The importance of evacuation of primary pontine hemorrhage in the chronic stage was recognized.

Clinicopathological study of pontine hemorrhage.

This report concerns a clinico-pathological study of 60 patients afflicted with primary pontine hemorrhage. The illness was fatal in 43, 17 patients survived. Ophthalmic signs, autonomic disturbances and transient visual hallucination were observed and discussed. A ruptured microaneurysm within the border of a pontine hematoma was detected in this study, and in the first report of such a finding.

Primary pontine hemorrhage and gustatory disturbance: clinicoanatomic study.

A clinicoanatomic study of 12 patients with tegmental-type primary pontine hemorrhage proved the presence of a gustatory disturbance among other clinical symptoms on the same side of the tongue as that of the pontine lesion, and suggested the secondary pathway of gustatory sensation from the solitary tract nucleus ascends without decussation in the homolateral pontine tegmentum. These results contradict textbook descriptions regarding the human secondary gustatory pathway.

BENIGN PRIMARY PONTINE HEMORRHAGE WITH CHEIRO-ORAL SYNDROME

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.

Juvenile Primary Pontine Hemorrhage

A 12-year-old boy was admitted in a comatose state following a sudden episode of headache and vomiting. General physical examination and vital signs at admission were normal. A difference was noted in pupil sizes, the right being slightly larger, and light reactions of both pupils were sluggish. Bilateral deep tendon reflexes were exaggerated and decerebrate posturing was elicited by noxious stimuli. There was right hemiparesis, but facial palsy was not be observed. A lumbar tap revealed an opening pressure of 230 mm H2O and the fluid was bloody. Ventricular drainage was performed the following day. Conray ventriculography showed a filling defect in the posterior end of the third ventricle, but the aqueduct of Sylvius and the fourth ventricle were not visualized. Computed tomography (CT) revealed the presence of a high density lesion in the area between the left paramedian pontine tegmentum and the fourth ventricle. It was diagnosed as a primary pontine hemorrhage, and a ventriculo-peritoneal shunt was performed. Left vertebral angiography failed to show any abnormal findings such as vascular malformation. Ten days after admission, anisocoria disappeared. The patient's consciousness became clear one month after the onset. With improvement of the level of consciousness, the following abnormal neurological findings were noted. Ocular movement indicated the presence of the one-and-a-half syndrome, i.e., complete loss of horizontal movement of both eyes except for lateral gaze of the right eye accompanied by nystagmus. There were left peripheral facial palsy and right hemiparesis with exaggerated deep tendon reflexes plus a right Babinski response. Right hemiparesis improved after about one year. A CT scan performed two years after the onset revealed a non-enhanced low density area in the pontine tegmentum where the hematoma had been located. At present, the patient is in good health and attending junior high school.

Clinical study of 20 cases of primary pontine hemorrhage. With special reference to correlations between clinical, computed tomographic, and electroencephalographic findings and outcome

Twenty cases of primary pontine hemorrhage (PPH) were diagnosed by CT scan over a period from June 1979 to March 1982, and were treated conservatively. They were classified into four types according to their outcome. Five cases in Type I showed a full recovery or could resume most activities (ADLI or II). The initial clinical picture of this type was characterized by alertness, no disturbance of autonomic function, and mild hemiparesis. CT scan demonstrated a small hematoma which was localized in the unilateral region or midportion of the pontine tegmentum. In four cases, the largest diameter of the hematoma on a transverse section through the pons was less than 20 mm, and its extension was limited to 2 slices, (each 10 mm in width). EEG performed on two patients were normal. Three cases of. Type II recovered to daily life partially assisted (ADL III). Clinical manifestations consisted of mild disturbance of consciousness, severe hemiplegia, cerebellar signs, and minor autonomic dysfunction. Hematoma was located in the bilateral pontine tegmentum and partially involved the pontine basis. The size of hematoma was less than 30 mm and its extension was 2 to 3 slices. EEG performed on one patient consisted of alpha activity with some theta waves. Seven cases of Type III were severely disabled in prolonged coma or the “locked-in” syndrome (ADL IV). Their clinical findings were coma in four patients, tetraplegia in seven, decerebrate regidity in two, respiratory disturbance in two, and hypertension in three. Hematoma was located in the entire pontine tegmentum and unilateral pontine basis extending to the midbrain. The size of hematoma was less than 30 mm in five patients and more than 31 mm in two. EEG was carried out on five patients in the comatose state. Alpha-pattern coma was present in two cases and beta-coma was observed in two. All five cases of Type IV died within a few days after the onset. The clinical picture was coma, tetraplegia, respiratory failure, hyperthermia, and hypertension in all cases. Hematoma involved the entire tegmentum and basis pontis and extended to the cerebellum and midbrain. The size of hematoma was less than 30 mm in two patients and more than 31 mm in three. The sagittal extension was 3 to 6 slices. The importance of systematic investigations of the clinical, computed tomographic, and electroencephalographic findings were recognized.