Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Review article: Biomedical intelligence

Vol. 149 No. 1314 (2019)

Management of brainstem haemorrhages

  • Sophie S. Wang
  • Yang Yang
  • Julia Velz
  • Emanuela Keller
  • Andreas R. Luft
  • Luca Regli
  • Marian C. Neidert
  • Oliver Bozinov
DOI
https://doi.org/10.4414/smw.2019.20062
Cite this as:
Swiss Med Wkly. 2019;149:w20062
Published
05.04.2019

Summary

Among spontaneous intracranial haemorrhages, primary non-traumatic brainstem haemorrhages are associated with the highest mortality rate. Patients classically present with rapid neurological deterioration. Previous studies have found that the severity of initial neurological symptoms and hydrocephalus are predictors of poor outcomes. In addition, radiological parameters aim to classify brainstem haematomas according to volume, extension and impact on prognosis. However, previous studies have failed to agree on a differentiated radiological classification for outcome and functional recovery. Electrophysiology, including motor, auditory and somatosensory evoked potentials, is used to estimate the extent of the initial injury and predict functional recovery. The current management of brainstem haematomas remains conservative, focusing on initial close neurocritical care monitoring. Surgical treatment concepts exist, but similarly to general intracranial haemorrhage management, they continue to be controversial and have not been sufficiently investigated. This is especially the case for haematomas in the posterior fossa, as these are excluded from most current clinical trials. Existing studies were mostly carried out before the present millennium began, and limitations are evident in the adaptation of those results and recommendations to current management, with today’s technological and diagnostic possibilities. We therefore recommend the re-evaluation of brainstem haemorrhages in the modern neurosurgical and intensive care environment.

References

  1. Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al.; American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Peripheral Vascular Disease; Council on Nutrition, Physical Activity and Metabolism. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(7):2064–89. doi:.https://doi.org/10.1161/STR.0b013e318296aeca
  2. Sacco S, Marini C, Toni D, Olivieri L, Carolei A. Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. Stroke. 2009;40(2):394–9. doi:.https://doi.org/10.1161/STROKEAHA.108.523209
  3. Sarti C, Rastenyte D, Cepaitis Z, Tuomilehto J. International trends in mortality from stroke, 1968 to 1994. Stroke. 2000;31(7):1588–601. doi:.https://doi.org/10.1161/01.STR.31.7.1588
  4. Dinsdale HB. Spontaneous hemorrhage in the posterior fossa. A study of primary cerebellar and pontine hemorrhages with observations on their pathogenesis. Arch Neurol. 1964;10(2):200–17. doi:.https://doi.org/10.1001/archneur.1964.00460140086011
  5. van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol. 2010;9(2):167–76. doi:.https://doi.org/10.1016/S1474-4422(09)70340-0
  6. Martin-Schild S, Albright KC, Hallevi H, Barreto AD, Philip M, Misra V, et al. Intracerebral hemorrhage in cocaine users. Stroke. 2010;41(4):680–4. doi:.https://doi.org/10.1161/STROKEAHA.109.573147
  7. Bozinov O, Hatano T, Sarnthein J, Burkhardt JK, Bertalanffy H. Current clinical management of brainstem cavernomas. Swiss Med Wkly. 2010;140:w13120.
  8. Nilsson OG, Lindgren A, Brandt L, Säveland H. Prediction of death in patients with primary intracerebral hemorrhage: a prospective study of a defined population. J Neurosurg. 2002;97(3):531–6. doi:.https://doi.org/10.3171/jns.2002.97.3.0531
  9. Murata Y, Yamaguchi S, Kajikawa H, Yamamura K, Sumioka S, Nakamura S. Relationship between the clinical manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. J Neurol Sci. 1999;167(2):107–11. doi:.https://doi.org/10.1016/S0022-510X(99)00150-1
  10. Masiyama S, Niizuma H, Suzuki J. Pontine haemorrhage: a clinical analysis of 26 cases. J Neurol Neurosurg Psychiatry. 1985;48(7):658–62. doi:.https://doi.org/10.1136/jnnp.48.7.658
  11. Wessels T, Möller-Hartmann W, Noth J, Klötzsch C. CT findings and clinical features as markers for patient outcome in primary pontine hemorrhage. AJNR Am J Neuroradiol. 2004;25(2):257–60.
  12. Choi JH, Mast H, Sciacca RR, Hartmann A, Khaw AV, Mohr JP, et al. Clinical outcome after first and recurrent hemorrhage in patients with untreated brain arteriovenous malformation. Stroke. 2006;37(5):1243–7. doi:.https://doi.org/10.1161/01.STR.0000217970.18319.7d
  13. Kidwell CS, Chalela JA, Saver JL, Starkman S, Hill MD, Demchuk AM, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004;292(15):1823–30. doi:.https://doi.org/10.1001/jama.292.15.1823
  14. Chung CS, Park CH. Primary pontine hemorrhage: a new CT classification. Neurology. 1992;42(4):830–4. doi:.https://doi.org/10.1212/WNL.42.4.830
  15. Dziewas R, Kremer M, Lüdemann P, Nabavi DG, Dräger B, Ringelstein B. The prognostic impact of clinical and CT parameters in patients with pontine hemorrhage. Cerebrovasc Dis. 2003;16(3):224–9. doi:.https://doi.org/10.1159/000071120
  16. Balci K, Asil T, Kerimoglu M, Celik Y, Utku U. Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage. Clin Neurol Neurosurg. 2005;108(1):36–9. doi:.https://doi.org/10.1016/j.clineuro.2005.02.007
  17. Fong C. Factors affecting the outcome in pontine hemorrhage. Acta Neurol Taiwan. 1999;8:6–11.
  18. Wijdicks EF, St Louis E. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology. 1997;49(5):1342–6. doi:.https://doi.org/10.1212/WNL.49.5.1342
  19. Rabinstein AA, Tisch SH, McClelland RL, Wijdicks EF. Cause is the main predictor of outcome in patients with pontine hemorrhage. Cerebrovasc Dis. 2004;17(1):66–71. doi:.https://doi.org/10.1159/000073900
  20. Uchino A, Hasuo K, Uchida K, Matsumoto S, Tsukamoto Y, Ohno M, et al. Olivary degeneration after cerebellar or brain stem haemorrhage: MRI. Neuroradiology. 1993;35(5):335–8. doi:.https://doi.org/10.1007/BF00588362
  21. Russell B, Rengachary SS, McGregor D. Primary pontine hematoma presenting as a cerebellopontine angle mass. Neurosurgery. 1986;19(1):129–33. doi:.https://doi.org/10.1227/00006123-198607000-00023
  22. Nishizaki T, Ikeda N, Nakano S, Sakakura T, Abiko M, Okamura T. Factors Determining the Outcome of Pontine Hemorrhage in the Absence of Surgical Intervention. Open Journal of Modern Neurosurgery. 2012;02(02):17–20. doi:.https://doi.org/10.4236/ojmn.2012.22004
  23. Ye Z, Huang X, Han Z, Shao B, Cheng J, Wang Z, et al. Three-year prognosis of first-ever primary pontine hemorrhage in a hospital-based registry. J Clin Neurosci. 2015;22(7):1133–8. doi:.https://doi.org/10.1016/j.jocn.2014.12.024
  24. Matsukawa H, Shinoda M, Fujii M, Takahashi O, Murakata A. Risk factors for mortality in patients with non-traumatic pontine hemorrhage. Acta Neurol Scand. 2015;131(4):240–5. doi:.https://doi.org/10.1111/ane.12312
  25. Jang JH, Song YG, Kim YZ. Predictors of 30-day mortality and 90-day functional recovery after primary pontine hemorrhage. J Korean Med Sci. 2011;26(1):100–7. doi:.https://doi.org/10.3346/jkms.2011.26.1.100
  26. Behrouz R. Prognostic factors in pontine haemorrhage: A systematic review. European Stroke Journal. 2018???:1-9.
  27. Shin S, Lim DJ, Kim SD. Primary pontine hemorrhage. an analysis of 35 cases and research in prognostic factors. Kor J Cerebrovasc Surg. 2007;9:41–5.
  28. Guérit JM. Neurophysiological testing in neurocritical care. Curr Opin Crit Care. 2010;16(2):98–104. doi:.https://doi.org/10.1097/MCC.0b013e328337541a
  29. Lee SY, Lim JY, Kang EK, Han MK, Bae HJ, Paik NJ. Prediction of good functional recovery after stroke based on combined motor and somatosensory evoked potential findings. J Rehabil Med. 2010;42(1):16–20. doi:.https://doi.org/10.2340/16501977-0475
  30. Moruzzi G, Magoun HW. Brain stem reticular formation and activation of the EEG. Electroencephalogr Clin Neurophysiol. 1949;1(4):455–73. doi:.https://doi.org/10.1016/0013-4694(49)90219-9
  31. Pallis C. ABC of brain stem death. The arguments about the EEG. Br Med J (Clin Res Ed). 1983;286(6361):284–7. doi:.https://doi.org/10.1136/bmj.286.6361.284
  32. Deletis V, Sala F. Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol. 2008;119(2):248–64. doi:.https://doi.org/10.1016/j.clinph.2007.09.135
  33. Deletis V, Fernández-Conejero I. Intraoperative monitoring and mapping of the functional integrity of the brainstem. J Clin Neurol. 2016;12(3):262–73. doi:.https://doi.org/10.3988/jcn.2016.12.3.262
  34. Slotty PJ, Abdulazim A, Kodama K, Javadi M, Hänggi D, Seifert V, et al. Intraoperative neurophysiological monitoring during resection of infratentorial lesions: the surgeon’s view. J Neurosurg. 2017;126(1):281–8. doi:.https://doi.org/10.3171/2015.11.JNS15991
  35. Seong JW, Kim MH, Shin HK, Lee HD, Park JB, Yang DS. Usefulness of the combined motor evoked and somatosensory evoked potentials for the predictive index of functional recovery after primary pontine hemorrhage. Ann Rehabil Med. 2014;38(1):13–8. doi:.https://doi.org/10.5535/arm.2014.38.1.13
  36. Schwarz S, Häfner K, Aschoff A, Schwab S. Incidence and prognostic significance of fever following intracerebral hemorrhage. Neurology. 2000;54(2):354–61. doi:.https://doi.org/10.1212/WNL.54.2.354
  37. Rincon F, Lyden P, Mayer SA. Relationship between temperature, hematoma growth, and functional outcome after intracerebral hemorrhage. Neurocrit Care. 2013;18(1):45–53. doi:.https://doi.org/10.1007/s12028-012-9779-9
  38. Hemphill JC, 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al.; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032–60. doi:.https://doi.org/10.1161/STR.0000000000000069
  39. Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, et al.; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–65. doi:.https://doi.org/10.1056/NEJMoa1214609
  40. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, et al.; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375(11):1033–43. doi:.https://doi.org/10.1056/NEJMoa1603460
  41. Boulouis G, Morotti A, Goldstein JN, Charidimou A. Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and meta-analysis of randomised trials. J Neurol Neurosurg Psychiatry. 2017;88(4):339–45. doi:.https://doi.org/10.1136/jnnp-2016-315346
  42. Broderick JP. The STICH trial: what does it tell us and where do we go from here? Stroke. 2005;36(7):1619–20. doi:.https://doi.org/10.1161/01.STR.0000170714.43167.34
  43. Da Pian R, Bazzan A, Pasqualin A. Surgical versus medical treatment of spontaneous posterior fossa haematomas: a cooperative study on 205 cases. Neurol Res. 1984;6(3):145–51. doi:.https://doi.org/10.1080/01616412.1984.11739680
  44. Takahama H, Morii K, Sato M, Sekiguchi K, Sato S. [Stereotactic aspiration in hypertensive pontine hemorrhage: comparative study with conservative therapy]. No Shinkei Geka. 1989;17(8):733–9.
  45. Hara T, Nagata K, Kawamoto S, Sashida J, Abe T, Wada A, et al. [Functional outcome of primary pontine hemorrhage: conservative treatment or stereotaxic surgery]. No Shinkei Geka. 2001;29(9):823–9.
  46. Nieuwkamp DJ, de Gans K, Rinkel GJ, Algra A. Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature. J Neurol. 2000;247(2):117–21. doi:.https://doi.org/10.1007/PL00007792
  47. Luney MS, English SW, Longworth A, Simpson J, Gudibande S, Matta B, et al. Acute posterior cranial fossa hemorrhage-is surgical decompression better than expectant medical management? Neurocrit Care. 2016;25(3):365–70. doi:.https://doi.org/10.1007/s12028-015-0217-7