Makindo Medical Notes

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.