Related Subjects:
|Subarachnoid Haemorrhage
|Perimesencephalic Subarachnoid haemorrhage
|Haemorrhagic stroke
|Cerebellar Haemorrhage
|Putaminal Haemorrhage
|Thalamic Haemorrhage
|ICH Classification and Severity Scores
🧠 About
- ⚠️ Poor Prognosis: Brainstem haemorrhage carries a very high fatality rate, often ≥50%.
- 📉 Rarity: An uncommon type of intracerebral haemorrhage (ICH), but devastating when it occurs.
🩸 Vascular Anatomy
- Midbrain & Pons: Supplied by paramedian perforators → bleeds are often bilateral and usually fatal due to critical structures.
- Short penetrating arteries: Supply lateral brainstem → haemorrhage may cause bulbar signs (cranial nerve involvement).
- Long circumferential arteries: Branches of AICA supplying lateral tegmentum → milder presentations with ataxia, sensory loss, hallucinations.
🧬 Causes
- 💢 Hypertension: Chronic small vessel rupture is the commonest cause.
- 🕸️ AVM: Congenital malformations prone to rupture.
- 🫀 Cavernoma: Dilated capillaries; bleeds are lower pressure, sometimes better prognosis.
🩺 Clinical Presentation
- Severe cases: 💥 Sudden coma, quadriparesis, pinpoint pupils (miosis), respiratory failure, sudden death.
- Cranial nerve involvement: CN V–VIII → facial weakness, gaze palsy, diplopia, hearing loss, vertigo.
- Milder cases: Ataxia, dizziness, nausea, vomiting, variable deficits.
🔍 Investigations
- 🧪 Coagulation screen: Rule out coagulopathy if suspected.
- 🖼️ Non-contrast CT: First-line to detect haemorrhage rapidly.
- 🧲 MRI/MRA: Defines extent, looks for AVM/cavernoma, evaluates surrounding tissue.
⚖️ Management
- 🛑 Conservative: Surgery rarely possible due to critical anatomy; supportive management is standard.
- 🏥 ICU care: Airway, ventilation, BP control, ICP management.
- 🧑🦽 Rehabilitation: For survivors, neuro-rehab is essential to adapt to residual deficits.
- 💊 Risk factor control: Strict BP management, vascular risk reduction to prevent recurrence.
📉 Prognosis
- Overall outlook is poor due to involvement of vital centres; survival rates are low.
- Survivors often left with profound neurological deficits.
📝 Notes
- 🩺 Early detection and treatment of hypertension is the most effective prevention.
- 🧑⚕️ Vascular malformations (AVMs, cavernomas) → consider neurosurgical input, though surgical options are limited in the brainstem.
💡 Exam Pearl: Sudden coma, quadriparesis, pinpoint pupils → think pontine haemorrhage.
