Rehabilitation of Hypertrophic Olivary Degeneration Secondary to Pontine Hemorrhage:One Case Report / 中国康复理论与实践

Objective To investigate the clinical and rehabilitation treatment of hypertrophic olivary degeneration(HOD)secondary to brainstem hemorrhage.Methods The clinical data of one patient with HOD secondary to pontine hemorrhage was retrospectively analyzed. In addition to the disability of the primary disease,involuntary jitter of the right limb gradually presented and aggravated.The patient re-ceived physical therapy,occupational therapy,acupuncture,hydrotherapy and medication.Results After one and a half-month rehabilitation and treatment,the patient improved from standing unsteadily and unable to walk to standing and walking independently.The score of Berg Balance Scale improved from 28 to 38,and the score of modified Barthel Index improved from 70 to 80.The involuntary jitter of the right limb was relieved.Conclusion The symptoms and disabilities of HOD secondary to pontine hemorrhage can be relieved by medication and rehabilitation,and the activities of daily living can be improved.

Pontine Necrosis Related with Radiation Therapy, Complicated with Spontaneous Hemorrhage

The brain necrosis induced by radiation therapy (RT) is an uncommon pathology of brain. A case of spontaneous hemorrhage at necrotic brain is also rare. A 52-year-old man who had nasopharyngeal carcinoma and had been treated with RT, presented with gait disturbance, dizziness, ataxia, dysarthria, and dysphagia. Magnetic resonance imaging (MRI) demonstrated progressed radiation necrosis of pons, and spontaneous hemorrhage at the site of necrosis. The hematoma was diminished by conservative treatment. However, the patient’s neurologic symptoms did not recover. Two years later, spontaneous bleeding recurred at necrotic brain. His neurologic symptoms worsened. One year later, his neurologic symptoms were more progressed. He showed severe dysphagia, profound weakness and respiratory failure. This case provides the description of relapsed spontaneous hemorrhage and medullary dysfunction caused by pontine necrosis and progressed post-radiation injury, complicated with hemorrhage, and urges caution in that the necrotic brain tissue may be vulnerable to bleeding.

A Case of Auditory Neuropathy Caused by Pontine Hemorrhage in an Adult

A pontine hemorrhage can evoke several neurological symptoms because the pons contains various nuclei and nerve fibers. Hearing loss can develop as a result of a pontine hemorrhage because there is an auditory conduction pathway in the cochlear nucleus of the pons. However, very few cases of hearing loss caused by pontine lesions have been reported, and there have been no reports of auditory neuropathy that developed following a pontine hemorrhage. Recently we had a patient who experienced a nontraumatic pontine hemorrhage who was diagnosed with auditory neuropathy. The 34-year-old male patient was admitted to the emergency department with sudden alteration of mental status. His brain computed tomographic imaging revealed a hemorrhage in the central pons. He complained of hearing difficulties after his mental status recovered through conservative treatment, but a pure-tone audiogram showed very mild hearing loss in both ears. Further hearing tests using otoacoustic emissions, which showed normal responses, and auditory brainstem responses, which showed no waveforms at maximum stimulus intensity, revealed that his hearing difficulties were caused by auditory neuropathy. This case implies that the threshold of sound detection can be preserved in patients with pontine hemorrhage who complain of hearing difficulties. Auditory neuropathy should be considered as a possible cause of hearing difficulties in these patients and appropriate hearing tests should be performed.

Usefulness of the Combined Motor Evoked and Somatosensory Evoked Potentials for the Predictive Index of Functional Recovery After Primary Pontine Hemorrhage

OBJECTIVE: To investigate the predictive index of functional recovery after primary pontine hemorrhage (PPH) using the combined motor evoked potential (MEP) and somatosensory evoked potential (SEP) in comparison to the hematoma volume and transverse diameter measured with computerized tomography. METHODS: Patients (n=14) with PPH were divided into good- and poor-outcome groups according to the modified Rankin Score (mRS). We evaluated clinical manifestations, radiological characteristics, and the combined MEP and SEP responses. The summed MEP and SEP (EP sum) was compared to the hematoma volume and transverse diameter predictive index of global disability, gait ability, and trunk stability in sitting posture. RESULTS: All measures of functional status and radiological parameters of the good-outcome group were significantly better than those of the poor-outcome group. The EP sum showed the highest value for the mRS and functional ambulatory category, and transverse diameter showed the highest value for "sitting-unsupported" of Berg Balance Scale. CONCLUSION: The combined MEP and SEP is a reliable and useful tool for functional recovery after PPH.

Hyperthermia Plus Tachycardia Is Predictive of Fatal Outcome in Pontine Hemorrhage: A Case Report / 대한구급학회지

Pontine hemorrhage is characterized by high mortality and morbidity. We report a case of pontine hemorrhage treated by extraventricular drainage (EVD) of cerebrospinal fluid (CSF) and control of intracranial pressure (ICP) at the neuro-intensive care unit (NICU). The patient's ICP was well controlled, but hyperthermia with tachycardia developed 8 hours after admission, and the patient expired with sudden cardiac arrest. A literature review revealed that high fever (>39degrees C) developing within 24 hours after onset of hemorrhage with tachycardia (>110 beat/min) is a clinical indicator for high probability of death. Therefore, it is important that not only ICP and neurological changes but also vital signs, especially body temperature and heart rate, be monitored in pontine hemorrhage patients.

Case Reports of Peduncular Hallucinosis in Patients with Pontine Hemorrhage : Two cases report

Peduncular hallucinosis that rarely reported in patients with brain stem lesion has several characteristics. The hallucination tends to be vivid, nonstereotypical images of person or animal. All the patients are aware that the hallucination is not part of reality. One of the suggested mechanisms of peduncular hallucinosis is imbalance among the cholinergic, serotonergic and other transmitting systems in the brain stem. We report two cases with typical features of peduncular hallucinosis which appeared about 30 and 12 months after pontine hemorrhage, respectively. We chose antipsychotics and selective serotonergic reuptake inhibitors for their medications, and their hallucinations disappeared about 2 months and 3 weeks after the medication, respectively. We suggest that peduncular hallucinosis should be considered in the patients with pontine hemorrhage if they complain of typical visual hallucinations.

Right Sensory Alien Hand Phenomenon from a Left Pontine Hemorrhage

BACKGROUND: Acute onset of a sensory alien hand phenomenon has been observed only from a supratentorial lesion involving the non-dominant hand, mostly from a right posterior cerebral artery infarction. A single acute vascular lesion resulting in a dominant hand sensory alien hand syndrome has not been previously documented. CASE REPORT: A 78-year old right-handed woman exhibited right sensory alien hand phenomenon from a left pontine hemorrhage. Disturbance of proprioceptive input and visuospatial perception are likely to play a role in manifesting the sign. CONCLUSIONS: Dominant-hand sensory alien hand phenomenon may occur in an acute setting from a left pontine hemorrhage.

Horizontal Ocular Tremor after Pontine Hemorrhage with Delayed Olivary Hypertrophy

No abstract available.

Primary Pontine Hemorrhage. An Analysis of 35 Cases and Research in Prognostic Factors / 대한뇌혈관외과학회지

OBJECTIVE: Primary pontine hemorrhage (PPH) accounts approximately for about 5~10% of intracranial hemorrhages, and overall mortality rate in recent studies is 40~50%. In a general way, primary treatment of PPH is conservative. Although some authors are trying to surgical treatment for PPH recently, treatment guideline still remains controversy. We report our study to establish the clinical and radiologic prognostic factors in PPH patients and present the guideline for surgical treatment. METHODS: We analyzed 35 patients with PPH admitted to our hospital between January 2000 and December 2006. Glasgow Coma Scale (GCS) scores were assessed on admission, and Glasgow Outcome Scale (GOS) scores on discharge. We divided the patients into two groups according to GOS score: (1) patients who had bad prognosis, and (2) patients who had good one. The two groups were compared for age, gender, hypertension, initial GCS, pupillary abnormalities, volume and location of hemorrhage, intraventricular and extrapontine extension, need for mechanical ventilation and hydrocephalus. RESULTS: Twenty-one patients (60%) were hypertensive. Twenty patients (57%) survived and six of them were capable of performing activities of daily living within 3 months of the hemorrhage. Significant prognostic factors were found with coma on admission, GCS score on admission, hematoma location, hematoma volume, need for mechanical ventilation and intraventricular hemorrhage. CONCLUSION: Initial GCS score, size and location of the hematoma, coma on admission, need for mechanical ventilation and intraventricular extension were significantly correlated to poor outcome in our study. If more large studies follow up including surgical outcome, we could make a surgical indication for PPH to improve the mortality and prognosis.

The Predictors of Survival and Functional Outcome in Patients with Pontine Hemorrhage

OBJECTIVE: Pontine hemorrhages usually result in a much higher morbidity and mortality than any other intracranial vascular lesion. The purpose of this study was to evaluate survival and the contributing factors for patients with pontine hemorrhage. METHODS: Of the 41 patients who were admitted to our hospital with their first acute pontine hemorrhage from 1997 to 2005, 35 patients were included in this study. Medical records were reviewed to confirm the accuracy of diagnosis and collect demographic, clinical and radiological data. The patients were divided into two groups, survivors and deceased patients; then the survivors were divided again into a group of patients with good results and those with poor results. The location of the hematoma, maximum anteroposterior (AP) diameter, maximum transverse diameter, hematoma volume, ventricular extension, extension into the midbrain, hydrocephalus and initial Glasgow coma scale (GCS) were evaluated. RESULTS: The two year survival rate was 58.5%. The survival of patients with pontine hemorrhage was affected by initial GCS score and transverse hematoma diameter. Functional outcome of patients who survived was affected by initial GCS, maximum transverse diameter, maximum AP diameter and hematoma volume. CONCLUSION: The rate of survival after pontine hemorrhage is associated with the transverse diameter of the hematoma and more importantly the initial GCS. Long-term outcome of survivors is influenced by the initial GCS, transverse diameter, AP diameter and volume. Through the multivariate analysis, initial GCS is the only significant factor on survival. Strictly speaking, initial GCS is not modifiable. However, surgical reduction may be considered to amend theses decisive factors. Additional study for indication, timing and method of surgical management is needed.

A Case of Horizontal Gaze Palsy with Ipsilateral Esotropia due to Pontine Hemorrhage

PURPOSE: We describe a patient with a horizontal pontine gaze palsy and a concurrent esotropia and discuss the etiology and surgical management of this condition. METHODS: A 42-years-old male visited the hospital with dipopia and left ocular pain. He had a history of pontine hemorrhage a year ago. Because of left ficial palsy, lagophthalmos was noted on the left eye and slit-lamp examination showed filament keraititis and superficial punctate keratitis. Left face turn was noted and a left horizontal gaze palsy with inability to abduct the left eye and to adduct the right eye past the midline was also noted. By Krimsky estimation, 40 prism diopter (PD) left esotropia was present in the primary position. Brain magnetic resonance imaging carried a yeas ago showed a large lobulated hyperdense lesion and the central lesion is on the left dorsal portion of pons. RESULTS: The patient underwent a right lateral rectus muscle recession of 5 mm, a left medial rectus muscle recession of 6 mm and a parial tendon transfer of the left superior and inferior rectus muscles th the left lateral rectus muscle insertion (modified Hummelsheim operation with augmentation). A lateral tarsorrhaphy was also performed. 3 months after operation, he didn't complain diplopia and orthotropia was noted in the primary position by Hirshberg test. His head posture was also right. The lagophthalmos and keratitis was markely improved and ocular pain was not complained. CONCLUSIONS: The lesion in this patient caused by potine hemorrhage may be involve the left PPRF, the left sixth nerve nucleus and the left facial nerve fascicles. Strabismus surgery on the patient improved diplopia and face turn.

Clinical Aspect of Spontaneous Pontine Hemorrhage / 대한뇌혈관외과학회지

OBJECT: Spontaneous pontine hemorrhage can be diagnosed by CT or MRI, but the clinical course is variable according to the location of the hemorrhage. MATERIALS AND METHODS: Author attempted to analyse 39 cases of spontaneous pontine hemorrhage, considering factors to influence their prognosis, admitted in Inje University Busan Paik Hospital from 1998 to 2002. RESULT: Pontine hemorrhage was classified according to the finding of CT scan;4 cases of Type I (hematoma, localized in the tegmentum), 18 cases of Type II (those in the tegmentolaterally), 16 in Type III (those in the basis pontis mainly with tegmentum and midbrain). Male to female ratio was 31:8, mean age was 48.2 years (9-76 years). Initial Glascow Coma scale was 7.6 (3-14), and mean follow-up period was 5.1 months (0.1-52 months). Associated diseases were as follows;hypertension;20, pulmonary tuberculosis;2, hypertension with D.M;1. Treatment modality was consisted of 36 conservative treatment, 1 stereotactic hematoma aspiration, 2 Gamma-Knife radiosurgery for associated cavernous malformations. Prognosis was good at following order of the tegmentotectal, tegmentolateral type. CONCLUSION: The prognosis of tegmentotectal, tegmentolateral type hemorrhage was better than basis pontis. The little volume of the hematoma, the better prognosis.

Isolated Trigeminal Sensory Change due to Lateral Pontine Hemorrhage Extending to the Trigeminal Nerve Root

No abstract available.

A Case of Bilateral Horizontal Gaze Palsy due to Pontine Hemorrhage

PURPOSE: To report a case of bilateral horizontal gaze palsy associated with pontine hemorrhage. METHODS: A 51-year-old man developed a sudden decrease in consciousness. Computed tomography reveal a pontine hemorrhage and infarctions of both basal ganglia. The mentality was recovered after conservative treatment, but he complained of difficulty in moving his eyes. We performed ophthalmic and radiologic evaluations to confirm a diagnosis of bilateral horizontal gaze palsy and to reveal the condition. RESULTS: On ophthalmic examination, his eye showed complete bilateral horizontal gaze palsy, but convergence and vertical eye movements were normal. Radiologic evaluation revealed a pontine hemorrhage, and the hemorrhagic area was consistent the bilateral paramedian pontine reticular formation (PPRF).

Combined Oculopalatine and Midbrain Tremor in Upper Limb Caused by a Pontine Hemorrhage

A 67-year-old man, with a history of pontine hemorrhage, was admitted because of ocular tremors. Also, tremors in the right upper limb and palates were detected. Oculopalatine tremors showed synchronous vertical oscillations and the limb showed midbrain tremor. Brain MRI revealed high signal intensities of both inferior olivary nuclei and right superior cerebellar peduncle. Electromyogram showed different tremor frequencies in the oculopalate and limb. Clinical, MRI and electromyographic findings indicate that the origins of oculopalatine and limb tremors are different.

Clinicoradiologic Study on Benign and Non-benign Pontine Hemorrhage

BACKGROUND: Since prognosis of pontine hemorrhage (PH) is dependent on the initial consciousness level, prediction of outcome is not difficult in patients presenting deeply comatose mentality or mild neurologic deficits without altered consciousness. The outcome of PH accompanied by some degree of altered mentality is, however, so various and cannot be easily predicted. The aim of this study was to analyze the radiologic factors determining the prognosis in this subgroup of PH. We also tried to describe the common clinical and radiologic features in patients with benign clinical course, which have rarely been studied systematically. METHODS: Chiefly based on the initial level of consciousness, 42 patients were classified into benign (BH, n=14), non-benign (NBH, n=19), and fatal (FH, n=9) PH. We retrospectively reviewed their medical records and radiologic data. The modified Rankin score was used for evaluating long-term prognosis. In NBH group, transverse and vertical extension index of hematoma, hemorrhage volume, and presence of extrapontine extension were investigated on CT images. RESULTS: Hemiparesis with or without ocular disturbance was the most common manifestation in BH group (64%) and two patients showed neurologic signs identical to lacunar syndrome. The most common location of hemorrhage was unilateral tegmentum (64%). In NBH group, transverse extension index was significantly greater in the patients with worse prognosis, though vertical extension index and extrapontine extension did not seem to be important in predicting the prognosis. CONCLUSIONS: The clinical features simulating lacunar syndrome are frequently found in BH. The degree of transverse extension in the pons is important in predicting the prognosis of NBH subgroup.

Pontine Hemorrhage after Surgical Evacuation of Nontraumatic Subdural Hematoma

Duret hemorrhage is characterized by an upper brainstem hemorrhage due to increased intracranial pressure by mass effect such as subdural hematoma or a brain tumor. The anteroposterior elongation and downward displacement of the upper brainstem by transtentorial herniation results in the compression and tearing of the paramedian perforating vessels that feed the upper brainstem tegmentum. The consequent hemorrhage that involves the upper brainstem renders recovery to be almost impossible. Following a tricuspid valve replacement surgery, a 56-year-old woman developed a left fronto-temporo-parietal nontraumatic subdural hematoma resulting in transtentorial herniation of the left mesial temporal lobe. A successful surgical evacuation of the hematoma was done with clinical improvement. Two days later, she was referred to neurology with an aggravated right side weakness, dysarthria, and a newly developed extraocular movement disturbance. A brain CT and MRI showed a pontine hemorrhage. We report a case of pontine hemorrhage, a Duret hemorrhage, after the surgical evacuation of nontraumatic subdural hematoma.

Surgical Outcome of Hypertensive Pontine Hemorrhages: Experience of 13 Cases

Hypertensive pontine hemorrhage usually causes profound, irreversible neurological deficits, with ominous prognosis, and is often fatal. There is controversy as to the appropriate treatment modality, but in general, surgical intervention is considered unethical. The authors report the outcome of hypertensive pontine hemorrhage in 13 patients whose Glasgow Coma Scale was 4-9, who on brain CT scan were seen to have over 10cc of hematoma and who underwent suboccipital craniectomy for hematoma removal. These patients could be divided in two groups: 'early'(9 patients), who underwent surgery within 24 hours of ictus, and 'late'(4 patients), who underwent surgery 6 to 20 days after ictus: all had shown neurological deterioration in spite of optimal medical treatment. Surgical outcome did not vary according to the extent of hematoma removal. For patients in the 'early' group, surgery was not useful, but three in the 'late' group, the GCS score improved to between 7 and 11. This study suggests that in hypertensive pontine hemorrhage, an early direct approach may not improve outcome, but for selected patients, who deteriorate during conservative treatment, surgery may be beneficial.

Clinical Analysis of the Factors Affecting the Prognosis of Spontaneous Pontine Hemorrhage

The prognosis of pontine hemorrhage has been reported to be extremely poor, but the wide-spread use of CT scan and MRI has led to the discovery of ssmall pontinehemorrhage which previously could not have been discovered. We analysed 28 cases of pontine hemorrhage for evaluation of contributing factors to the patients prognosis from January 1994 to December 1996. A good prognosis was achieved in patients with no or mild disturbance of consciousness, 20mm or less in the transverse diameter of the hematoma, small numbers of slices in which the hematoma was found, and the hematoma localized in the tegmentum. Two patients underwent suboccipital craniectomy with removal of hematoma. But all patients died immediate postoperative period. A comatose state on admission, transverse diameter of hematoma over 20mm, large numbers of slices in which the hematoma was found, and the hematoma localized in the basotegmentum were significant poor prognostic factors.

Prognostic Factors in Spontaneous Cerebellar Hemorhage and Pontine Hemorrhage

The author studied 62 consecutive patients with spontaneous cerebellar hemorrhage and 38 patients with spontaneous pontine hemorrhage, diagnosed by computerized tomography scanning from May 1983 to December 1994 and assessed the relationship of outcome of initial GCS score, CT findings, and treatment modality. In cerebellar hemorrhage, good outcome was achieved in patients with high initial GCS score(>13), small hematoma, patent quadrigeminal cistern, absent hydroceohalic change, and the location of the hemorrhage in the hemisphere. Although the size of hematoma was an impotant prognostic factor, it had no constant bearing on the level of consciousness, degree of quadrigeminal cistern obliteration, and outcome. Absence of quadrigeminal cistern obliteration predicted a good outcome whether the hematoma was evacuated or not, as long as obstructive hydrocephalus, if present, was relieved darly. However, partial obliteration of the quadrigeminal cistern was a predictor of good outcome if the hematoma was evacuate d within 48 hours after the onset of hemorrhage. Total obliteration of the quadrigeminal cistern inevitably predicted an unfavorable outcome. In pontine hemorrhages, a good outcome was achieved in patients with high initial GCS score(>13), small size hematoma(10cc) inevitably showed an unfavorable outcome.