954

Lateral Pontine Hemorrhage:Reappraisal of Benign Cases

Oscar H. Del-Brutto, MD, Carlos A. Noboa, MD, and Fernando Barinagarrementerfa, MD

We reviewed 6 computed tomography-documented cases of primary lateral pontine hemorrhage thatoccurred in our two institutions over a 2-year period. All patients survived the acute stroke, withexcellent functional recovery in 4. The level of consciousness of the patient and the size of thehemorrhage had no consistent bearing on outcome. Both of these features have been consideredimportant prognostic indicators in patients with pontine hemorrhage, but in our series benign out-comes were not restricted only to patients who were alert or had small hemorrhages; on the otherhand, severe disability was noticed in 1 patient with a small hematoma strategically located in thepontine tegmentum. Our observations suggest that, although some patients with lateral pontinehemorrhage have a good prognosis, there is no single determinant that predicts outcome in a givenpatient. (Stroke 1987;18:954-956)

The classic syndrome of pontine hemorrhage in-cludes coma, respiratory abnormalities, pin-point pupils, loss of horizontal eye move-

ments, quadriplegia, and bilateral corticospinal tractdysfunction. '~3 Ocular bobbing4 and hyperthermia mayalso be present. Most patients die within the first 24hours after the acute event.' At necropsy, the hemato-ma usually involves the entire pons with extension intothe midbrain and the fourth ventricle.2

In recent years, several cases of pontine bleedingwith favorable outcome and unexpected clinical mani-festations have been reported.5"20 Widespread use ofcomputed tomography (CT) has led to better recogni-tion of such relatively benign cases.21 In most of thesepatients the hematoma was small and confined to oneside of the pons.5^10"1418"20 Such reports have changedprevious concepts about invariance of the lethal out-come of pontine hemorrhage and have prompted manyauthors to recognize features that are common to thebenign cases.3"8 In this paper, we report 6 cases oflateral pontine hemorrhage to further outline the clini-cal features, CT findings, and outcome of theselesions.

Subjects and MethodsWe reviewed all CT-documented cases of lateral

pontine hemorrhage that occurred in our institutionsover a 2-year period. After exclusion of bleeding asso-ciated with arteriovenous malformations, tumors, ortrauma, we found 6 cases of primary hemorrhage thatrepresent the material for this study. Special emphasiswas placed on the level of consciousness at admission

From the Division de Neurologia, Institute) Nacional de Neuro-logia y Neurocirugia, Mexico DF, Mexico (O.H.D., F.B.) and theDepartamento de Neurologia, Hospital Luis Vemaza, Guayaquil,Ecuador (C.A.N.).

Presented at the 10th Annual Meeting of the Mexican Academyof Neurology, Guadalajara, November 4, 1986.

Address for reprints: Oscar H. Del-Brutto, MD, Institute Na-cional de Neurologia y Neurocirugia, Insurgentes Sur, No. 3877,CP: 14410 Mexico 22, DF.

Received October 24, 1986; accepted May 18, 1987.

and on CT findings to further correlate both featureswith the outcome in every patient (Table 1).

ResultsFour patients were women, 2 men. Ages ranged

from 38 to 76 years, with a median of 51 years. Arteri-al hypertension was present in 4 patients. One patientwas taking oral amphetamines for obesity. Onset wasabrupt in 5 patients; gradual progression over a 48-hour interval was seen in 1 patient. Headache andalteration in consciousness appeared as prominentsymptoms. On admission, 3 patients were in a coma, 1was somnolent, and 2 were alert. Two of the 3 patientsinitially in a coma regained full consciousness 72 and96 hours later. Frequent neurologic signs were ocularparesis, small reactive pupils, dysarthria, hemiplegia,and limb ataxia. CT scans showed lateral hematomasin all cases. In all but 2 patients, the hemorrhage in-volved the basal and tegmental pons. Rostral extensionwas documented in 2 cases. In 2 patients, the hemor-rhage invaded the fourth ventricle with obstruction andsecondary hydrocephalus. All patients survived theacute stroke. One patient died of aspiration pneumoniawhile recovering from the stroke, 4 patients showedalmost complete recovery with minor motor sequelae,and the last patient was severely incapacitated 1 monthafter the stroke.

DiscussionLateral pontine hemorrhage was recognized before

the availability of CT1>2>22; however, it was consideredrare.2 Using CT, it is clear that the incidence of lateralpontine hemorrhage is greater than previously appreci-ated and the clinical signs more varied.6"20 Two clinicalsyndromes of hemorrhage confined to one side of thepons have been described.6-23 In one, the hematomainvolves both the basis pontis and tegmentum and isassociated with crossed hemiparesis and ipsilateralbrainstem signs. In the other, the hematoma is con-fined to the tegmentum and is associated with ipsilat-eral brainstem signs. The clinical picture in every pa-tient of our series was consistent with one of these

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Del-Brutto et al Lateral Pontine Hemorrhage 955

Table 1. Level of Consciousness, Computed Tomography Findings, and Outcome in 6 Patients with LateralPontine Hemorrhage

Case/sex/age

l/F/76

2/F/43

3/F/38

4/F/39

5/M/48

6/M/62

Level of consciousness

Sudden coma; alert 96 hours later

Somnolence

Sudden coma; stupor few hourslater

Alert

Sudden coma; alert 72 hours later

Alert

Computed tomography

Right pontine hemorrhage withblood in fourth ventricle;hydrocephalus

Left pontine hemorrhage with ros-tral extension into midbrain

Small hemorrhage in right pontinetegmentum; blood in fourthventricle; hydrocephalus

Small hemorrhage in right side ofpons

Left pontine, midbrain hemorrhage

Right pontine hemorrhage

Outcome

Excellent

Excellent

Bedridden

Excellent

Died of aspiration pneumonia

Excellent

pontine syndromes, and CT findings correlated closelywith the neurologic manifestations. Previous reportsstress the presence of arterial hypertension in 60-90%of the cases.125"7 In the present cases, 4 of 6 patientswere hypertensive. It is important to note oral amphet-amine ingestion in 1 patient. The association betweenintracerebral hemorrhage and the use of oral2423 orintravenous26 amphetamines has been noted, but to ourknowledge this is the first case of pontine hemorrhagesecondary to amphetamine abuse.

Another important feature of patients with lateralpontine hemorrhage is their good prognosis. In mostseries, a benign outcome was noted when conscious-ness was not severely impaired at admission.5"1318 Thetransverse diameter of the hematoma has also beenconsidered a prognostic factor. Masiyama et al8 founda direct relation between the maximum transverse di-ameter of the hematoma seen in CT scans and theoutcome. In their series, a diameter of < 2 0 mm wasassociated with favorable outcome.

FIOURE 1. Computed tomogram showing a 14 x 16 mm he-matoma in the right pontine tegmentum.

While the level of consciousness at admission andthe transverse diameter of the hematoma predicted theoutcome of patients with pontine hemorrhage in someinstances, we found exceptions to both as indicators.There was spontaneous recovery in 2 of the patients ina coma at onset and severe disability in the patient withthe smallest hemorrhage of our series (Figure 1). Wecould not find any single determinant that predicts agood prognosis in every patient with lateral pontinehemorrhage.

Systemic complications can be a major cause ofmorbidity and mortality in patients who survive theacute hemorrhage.37 Nakajima7 found a 15% incidenceof gastrointestinal bleeding in patients who survived> 8 days after the stroke. Other common disturbancesin his series were neurogenic bladder and autonomicdysfunction. Caplan and Goodwin5 reported a highmortality rate (44%) from causes not related to thepontine hemorrhage. In our series, only 1 patient diedfrom systemic complications while recovering fromthe stroke.

Treatment of patients with lateral pontine hemor-rhage should be conservative. Although there havebeen isolated reports of successful removal of pontinehematomas,27"30 several other studies have documentedthat medical management has been sufficient to permitrecovery in similar cases.3"15 With the present knowl-edge, there is no place for surgery in the managementof lateral pontine hemorrhage with the exception ofshunting patients with persistent hydrocephalus.618

AcknowledgmentThe authors wish to thank Dr. Vladimir Hachinski

for reviewing the original manuscript.

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19. Cascino GD, Adams RD: Brainstem auditory hallucinosis.Neurology 1986;36:1042-1047

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KEY WORDS • pontine hemorrhage • posterior fossahemorrhage • lateral brainstem hemorrhage • brainstemsyndromes

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O H Del-Brutto, C A Noboa and F BarinagarrementeríaLateral pontine hemorrhage: reappraisal of benign cases.

Print ISSN: 0039-2499. Online ISSN: 1524-4628 Copyright © 1987 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke doi: 10.1161/01.STR.18.5.954

1987;18:954-956Stroke. 

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