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  • Updated 12.02.2020
  • Released 02.28.1995
  • Expires For CME 12.02.2023

Brainstem hemorrhage

Introduction

Overview

Brainstem hemorrhage may be a devastating disorder presenting with a broad range of symptoms. Bleeding may be due to trauma, stroke, underlying vascular malformations, or a spectrum of rare disorders. CT and MRI have expanded diagnosis and our understanding of this disorder. Management considerations are highlighted in this overview of brainstem hemorrhage.

Key points

• Brainstem hemorrhage is often a devastating condition.

• Clinical manifestations may range from isolated deficits to coma.

• Hypertension is the most common risk factor.

• MRI may provide further detail and aid prognosis.

• Surgery is reserved for select cases in which specific expertise is available.

Historical note and terminology

Brainstem hemorrhage was first described by Cheyne in 1812 (15) in a pathological study of patients presenting with lethargy and coma. In 1877 Bode reviewed findings of 67 patients reported in the literature (07). Gowers noted that loss of consciousness was not an essential feature and that patients frequently presented with seizures (30). In 1900 Oppenheim described the clinical features of pontine hemorrhage in detail (68). The chronological history of brainstem hemorrhage has been reviewed (93; 31).

Reports on brainstem hemorrhages outside the pons were rare prior to the CT scan era, perhaps because the condition was mild and often confused with brainstem infarction. Clinical and pathological description of hemorrhages in the midbrain and medulla were described after the introduction of cranial CT scanning. Even with CT, detection of small Duret hemorrhages may be limited (50). CT also brought awareness of "benign variants" of brainstem hemorrhages (81).

The underlying mechanism producing the hemorrhage is secondary to vascular damage, most commonly from hypertension (22). The resulting hemorrhage leads to severe destruction of the brainstem and often carries a grave prognosis (13). In young individuals, hemorrhages may develop in the absence of hypertension. Such lesions are frequently secondary to vascular malformations (49). The hematomas are often small and produce milder deficits. In many patients with such vascular lesions, surgical evacuation of the hematoma may result in early improvement (49; 84). Surgical excision may prevent recurrences. Rarely, small hemorrhages may be secondary to lacunar disease (type II lacunae) (11). The clinical picture in such patients is similar to ischemic lacunar involvement of the brainstem (11). Brainstem hemorrhage, in order of frequency, is seen in the pons, midbrain, and medulla.

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