The Clinical Consideration on the Prognosis of the Pontine Hematoma

Pontine hematoma would be diagnosed and made its follow-up readily as the extent of hematoma could be clearly defined since the CT scan was available, especially with MRI in recent. Authors attemped to analyse 20 cases of pontine hematoma clinically, considering factors of influence their prognosis, admitted in Inha hospital from March 1989 to February 1992. Classification of pontine hematoma was made out according to the findings of brain CT scan taken on admission:2 cases of Type T1 to the hematoma localized in the tegmentum unilaterally, 1 case of Type T to those in the tegmentum bilaterally with some extent into the 4th ventricle, 12 in Type T to those in the tegmentum, midbrain and mostly the 4th ventricle, and 5 in Type B to those in the basis pontis mainly with tegmentum and midbrain. Of 219 spontaneous intracerebral hematoma, pontine hematoma was 9.1%. 17 hypertension and 11 previous CVA episodes including 7 cerebral infarction and 4 ICH were endountered. Age distribution was 50% in 6th decade and male to female ratio was 3:2. On admission 14 cases were under 6 in Glasgow coma scale, 6 small reactive pupils and 11 ocular bobbing. Particularly, nuclear facial paralysis was 14 in initial bilateral type, of which 7 dead within 10 days, 5 fixed in left facial paralysis and 1 case into right paralysis later. Four surgical interventions were 1 simple EVD, 1 Urokinase irrigation through EVD, 1 steretactic aspiration and 1 direct hematoma removal. Prognosis was related to various factos:GCS on entry, volume and classification of hematoma, in addition to laterality of nuclear facial paralysis. Clinical course was better in cases over 10 GCS on entry, volume and classification of hematoma, in addition to laterality of nuclear facial paralysis. Clinical course was better in cases over 10 GCS, Type T1 and T2, and unilateral facial paralysis in which the ratio of left to right was 2:1, while it was very poor in patients who were GCS below 6, Type B and bilateral facial paralysis. On the contrary, 7 of 20 cases were dead within 10 days, 13 patients alive for more 3 months after the hemorrhage were observed with fixed facial paralysis in nuclear type, 1 ilateral, 4 right, and 8 left side. It is suggested and requested for further careful follow-up that the hemorrhage may occur from the border zone between paramedian, short and long circumferential arteries supplying transection area of the pons unilaterally, near on around the facial nucleus, more frequent in left side.

Treatment of Pontine Hemorrhage

Most of untreated pontine hematoma are known to be fatal. Even though the patient may survive, the sequelae of pontine hematoma is serious. Fourteen cases of pontine hematoma who were treated either surgically or conservatively were analysed. Among nine cases treated surgically, three showed good recovery, three died postoperatively, and moderate to severe disability remained in three cases. On the other hand, conservative treatment resulted in one good recovery, one moderate disability, and four deaths. We hope to emphasize the efficacy of surgical treatment on pontine hematoma.

Surgical Treatment of Pontine Hematoma

Three cases of pontine hematoma accompanied by serious neurological symptoms with coma were treated surgically. All patients underwent suboccipital craniectomy with removal of hematoma and subsequently ventriculoperitoneal shunts were needed in all cases. Postoperatively all cases showed improvement with some neurological sequelae remained. Most of untreated pontine hematoma may be fatal, whereas surgical evacuation of the hematoma is safe and promising. We emphasize surgical treatment of pontine hematoma should be considered in any cases though they show serious neurological deficits.