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Brainstem hemorrhage

By David S Liebeskind MD (Dr. Liebeskind of the University of California, Los Angeles received consulting fees from Stryker and Covidien.)
Originally released February 28, 1995; last updated January 13, 2015; expires January 13, 2018

Introduction
This article includes discussion of brainstem hemorrhage, medullary hemorrhage, midbrain hemorrhage, and pontine
hemorrhage. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
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 recently
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 (Cheyne 1812) in a pathological study of patients
presenting with lethargy and coma. In 1877 Bode reviewed findings of 67 patients reported in the literature (Bode
1877). Gowers noted that loss of consciousness was not an essential feature and that patients frequently presented
with seizures (Gowers 1893). In 1900 Oppenheim described the clinical features of pontine hemorrhage in detail
(Oppenheim 1905). The chronological history of brainstem hemorrhage has been reviewed (Thompson 1988; Haines
and Molman 1993).
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 (Marupaka and Sood 2008). CT also brought awareness of "benign variants" of
brainstem hemorrhages (Shuaib 1991).
The underlying mechanism producing the hemorrhage is secondary to vascular damage, most commonly from
hypertension (Dinsdale 1964). The resulting hemorrhage leads to severe destruction of the brainstem and often carries
a grave prognosis. In young individuals, hemorrhages may develop in the absence of hypertension. Such lesions are
frequently secondary to vascular malformations (Mangiardi and Epstein 1988). 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 (Mangiardi and Epstein 1988; Stea et al 1994). Surgical excision may prevent recurrences.
Rarely, small hemorrhages may be secondary to lacunar disease (type II lacunae) (Challa and Moody 1989). The
clinical picture in such patients is similar to ischemic lacunar involvement of the brainstem (Challa and Moody 1989).
Brainstem hemorrhage, in order of frequency, is seen in the pons, midbrain, and medulla.

Clinical manifestations
Presentation and course
The presenting features depend on the size and location of the hemorrhage. Headache and focal brainstem signs are
seen in most patients. Headaches are usually associated with vomiting and are more common in women or patients
younger than 70 years of age (Melo et al 1996). However, the frequency of headaches is not as common with deep
hematomas (brainstem) compared to lobar or cerebellar hemorrhages (Melo et al 1996). Depending on the location of

the hemorrhage, the patient may present with diplopia, incoordination, cranial nerve signs, vertigo, tinnitus,
hyperacusis, tremor, dysarthria, dystonia, hyperthermia, breathing dysfunction, and long-tract signs (Chhetri et al
2014). With large hemorrhages, especially in patients with hypertension or an underlying vascular malformation, there
may be a rapid progression to coma. Intracranial hemorrhage is an important cause of acute neurologic dysfunction
and accurate early diagnosis of cortical versus brainstem hemorrhage, with initiation of appropriate therapy, may help
to minimize morbidity (Stieg and Kase 1998).
Most hemorrhages occur in the ventral region of the brainstem. This region is supplied by 3 groups of arteries. The
paramedian branches supply the basal region. Short and long circumferential arteries supply the tegmentum.
Hemorrhages commonly occur in the distal branches of these arteries (Kase and Caplan 1986). In the pons,
hemorrhages restricted to the basal region involve the pontine nuclei, corticospinal, corticobulbar, and corticopontine
tracts. Hemorrhages in the circumferential arterial territory involve cranial nerves, sensory tracts, autonomic tracts,
and cerebellar peduncles. In the pons, lesions in the short circumferential artery distribution usually result in ipsilateral
cerebellar disturbances and autonomic disturbances, and contralateral sensory deficits. Lesions of the long
circumferential arteries, in addition to the cerebellar and sensory deficits, also involve cranial nerves producing lateral
gaze palsy, and facial sensory or motor disturbances. Pontine hemorrhages may also become clinically manifest due to
isolated eye and facial pain, described as salt-and-pepper pain (Chen et al 2012).
Pontine hemorrhage. Patients with a large central hemorrhage present with a progressive decrease in the level of
consciousness rapidly leading to coma. Bilateral bulbar muscle weakness, "pinpoint" pupils, hyperthermia, and
hyperventilation are common associated findings (Silverstein 1982). This presentation is seen most often in patients
with uncontrolled hypertension (Dinsdale 1964). Contralateral hyperhidrosis in the subacute or late phase after pontine
hemorrhage may be seen. This is thought to be secondary to disruption of contralateral inhibitory sweating pathway
(Sato and Nitta 2000). Up to one third of patients may develop a severe headache before the onset of focal signs
(Dinsdale 1964). Vomiting may be seen in 20% of patients, and seizures (mostly flexor spasms and not true
convulsions) have been reported in 30% of patients (Dinsdale 1964).
Physical examination reveals an increased temperature and abnormal breathing patterns in 70% of patients.
Ophthalmological examination may show small pupils, absence of horizontal eye movements, and ocular
bobbing.{embed="pagecomponents/media_embed" entry_id="7960"} With large hemorrhages, bulbar musculature is
invariably affected. This may increase the risk of aspiration. Silent aspiration may be difficult to recognize in the
comatose patient. Massive pontine hemorrhage is invariably fatal; 80% of patients die within 48 hours (Silverstein
1982). In a large study, 70% of the patients were comatose at admission, and 78% were dead in 48 hours (Dinsdale
1964). Most hemorrhages occurred in the midpons at the junction of basis pontis and tegmentum. Hemorrhages
frequently spread to the midbrain but rarely into the medulla. They frequently rupture into the fourth ventricle
(Dinsdale 1964). Most recently, pontine microbleeds have been described in the setting of CADASIL (Oh et al 2014).
Smaller hemorrhages in the tegmentum or basal regions may present with focal signs and no alteration in
consciousness (Shuaib 1991). Such small hemorrhages are usually unsuspected until after the CT or MR scans.
Hemorrhages restricted to the basal region present with hemiplegic deficits or ataxia-hemiparesis (Gobernado et al
1980; Schnapper 1982). There are rare reports of auditory hallucinosis (Cambier et al 1987). Clinically, such
syndromes are indistinguishable from lacunar infarction in the same region. With hemorrhages restricted to the lateral
tegmentum, sensory deficits, ataxia, and oculomotor abnormalities (one-and-one-half syndrome, internuclear
ophthalmoplegia, horizontal gaze palsies and ocular bobbing) are common findings (Payne et al 1978; Caplan and
Goodvin 1982). Isolated symptoms such as sixth nerve palsy, sometimes bilateral (Kellen et al 1988), hemisensory or
isolated facial sensory (Toratani et al 2008) disturbances, or trigeminal neuropathy (Berlit 1989) have been reported
with small hemorrhages. Dystonia may be associated with pontomesencephalic lesions (Loher and Krauss 2009).
Phantom arm and leg phenomena have been noted after pontine hemorrhage (Tanaka et al 2008). Early recovery is
seen in most patients, and complete resolution of deficits is common. In a study of 80 patients with primary pontine
hemorrhage, the initial level of consciousness and the transaxial size of hematoma on CT were strongly related to the
outcome (Murata et al 1999).
Midbrain hemorrhage.{embed="pagecomponents/media_embed" entry_id="7961"} Spontaneous midbrain
hemorrhages were considered rare until relatively recently. The first case was reported in 1949 (Scoville and Poppen
1949). The clinical diagnosis of a brainstem tumor was changed to hemorrhage after the surgery. Between 1978 and
1991, more than 20 additional patients were reported in the literature (Shuaib 1991). In most patients, the diagnosis of

midbrain hemorrhage was not suspected until after a CT or MRI. Isolated case reports may reveal subtle or minimal
symptoms due to restricted involvement such as monoaural tinnitus due to contralateral inferior colliculus hemorrhage
(Stimmer et al 2009). Neuro-ophthalmological involvement is prominent in most patients. Third nerve dysfunction,
skew-deviation, gaze palsy (especially in the vertical axis), and pupillary irregularities are common (Keane 1988).
Parinaud syndrome (superior gaze palsy, pupillary dysfunction, and tonic downward and medial deviation of the eyes)
is seen with hemorrhages in close proximity to the posterior commissure (Fingerote and Shuaib 1990; Shuaib 1991).
Third nerve involvement may be unilateral or bilateral. With unilateral involvement, there may be partial or complete
paralysis of function, and the affected lesion may involve the nucleus or the third nerve fascicle. With fascicular
involvement, motor long tracts may be affected in the cerebral peduncle (Weber syndrome). Isolated fourth nerve
palsy may also be a rare manifestation (Lee 2010; Raghavendra 2010). Patients may have ataxia (from involvement of
the superior cerebellar tract in the midbrain), sensory dysfunction (Berlit 1989), and motor dysfunction (from
involvement of the long tracts passing through the midbrain). Unilateral asterixis (Fingerote and Shuaib 1990), cheirooral syndrome (sensory disturbance around the arms and mouth) (Yasuda et al 1988), and behavioral abnormalities
(Mehler and Ragone 1988) have occasionally been demonstrated. Hemorrhages close to the aqueduct can produce an
acute hydrocephalus that may need urgent surgical intervention. Recovery in most patients with a small hemorrhage
is rapid and often complete. In patients with an underlying arteriovenous malformation, recurrence may commonly be
seen (Abe et al 1989).
Medullary hemorrhage. Hemorrhage in the medulla is the least common type of brainstem hemorrhage; the first
report was published in 1964 and discussed a patient who had Wallenberg syndrome (Kempe 1964). A brainstem
tumor was suspected. Surgery revealed an unexpected hemorrhage. On occasion, tumors such as hemangioblastoma
may cause medullary hemorrhage (Ryang et al 2007). Posttreatment radiation injury of tumors in this region may also
lead to hemorrhage (Liu et al 2007). In most patients, it has been difficult to determine if the hemorrhage was confined
to the medulla or extended into the pons (Arseni and Stanciu 1973; Rousseaux et al 1988; Chytte 1989; Shuaib 1991).
Vertigo, ataxia, lower cranial nerve abnormalities, and breathing dysfunction can develop with hemorrhages in the
medulla (Shuaib 1991). Central hypoventilation can develop suddenly and early after the hemorrhage and can lead to
respiratory arrest (Shuaib 1991). Breathing difficulties are particularly bothersome during sleep resulting in repeated
apneic spells (Thalhofer and Dorow 1997). Headache is common, and neck stiffness has been reported. Tongue
weakness, down beating nystagmus (Rousseaux et al 1991), and autonomic dysfunction may be seen. Breathing
difficulties may not resolve for a long time, and some patients may require tracheostomy for ventilatory support. The
occasional patient may be severely disabled with the vertigo or ataxia.
Prognosis and complications
The prognosis with brainstem hemorrhage depends on the size and location of the hemorrhage. With large pontine
hemorrhages that involve the basis pontis and tegmentum, 78% of patients may die in the first 48 hours, with the
majority dying in the first 24 hours. Autonomic dysfunction and respiratory arrest are the common causes of early
death. Later, pneumonia and other infections, venous thrombosis with pulmonary emboli, and other systemic causes
may complicate recovery. A high correlation has been observed between a poor outcome (Glasgow outcome score <
4) and hematoma volume greater than 4 mL, ventral hemorrhage, and necessity for mechanical ventilation (Wessels
et al 2004). Aggressive management may also lead to good prognosis in selected cases (Stiver et al 2009), but
brainstem hematomas generally have a poor prognosis (Rohde et al 2007).
In patients with small hemorrhages located in the pontine tegmentum or the midbrain, prognosis for recovery is
excellent. Recovery begins within 24 hours, and most patients may be discharged from the hospital within a week. In
our experience, a complete recovery occurs 6 weeks to 8 weeks after the onset. Recurrence may occur in patients with
an arteriovenous malformation (Abe et al 1989). In patients with milder symptoms and no defined etiology, recurrence
is rare.
A recent multivariate analysis demonstrated bilateral hematoma extension, a Glasgow Coma Scale score of less than
or equal to 8, presence of hydrocephalus, gender, and hematoma volume to all be significantly associated with 3month mortality, whereas Glasgow Coma Scale score less than or equal to 8, the presence of a pupillary abnormality,
and hematoma volume were found to be associated with the 3-month poor outcome (Takeuchi et al 2013).
Clinical vignette
A 43-year-old woman presented with several months of fluctuating headaches that culminated in acute presentation

with severe headache, marked hypertension, diplopia, bilateral numbness, and paraparesis. MRI revealed a large
cavernous angioma of the pons with evidence of recurrent hemorrhage.{embed="pagecomponents/media_embed"
entry_id="7962"} Although surgical evacuation was considered, it was deferred due to the deep location and expected
high complication rate. Conservative medical management over 4 years was punctuated by recurrent bleeds with
chronic fatigue, diplopia, and bladder dysfunction although her sensory and motor deficits improved with time.

Biological basis
Etiology and pathogenesis
The most common underlying problem with large hemorrhages is uncontrolled hypertension (Dinsdale 1964), as may
be seen in more than 80% of patients with large pontine hemorrhages. Arteriovenous malformations may account for a
small minority of patients, especially with recurrent hemorrhages. Patients with no obvious underlying etiology may
have a milder clinical course. In 1 report of 164 patients with posterior fossa vascular malformation, arteriovenous
malformations had the greatest tendency to bleed (McCormick et al 1968). Among the 12 lesions that bled, 9 lesions
were arteriovenous malformations, and 3 lesions were venous angiomas (McCormick et al 1968). Most of the
arteriovenous malformations were in the pons. Besides arteriovenous malformations, telangiectasias and cavernous or
venous malformations also frequently occur in the brainstem. Telangiectasias and venous malformations rarely bleed.
Of the 27 lesions in the above mentioned series, none were associated with any sign of remote or recent hemorrhage.
Other rare etiologies include hemorrhage into a tumor, brainstem infarction or cyst, vasculitis, trauma, postradiation
degeneration, aneurysms, and amyloid (Nedergaard et al 1983; Meyer et al 1991; Chung et al 1992; Matsumaru et al
1996; Yuen and Johnson 1996; Liu et al 2007; Watanabe et al 2008; Kleinig et al 2009; Takeuchi et al 2011; Ohtani et
al 2014). Repeated hemorrhage has also been reported from a melanoma mistaken as a cavernoma (Watanabe et al
2008). Drug-induced hemorrhage is rare in the brainstem. It may be seen with an overdose of anticoagulants or may
be related to street-drug abuse (Broucker et al 1989; Miyashita et al 2007). A massive brainstem hemorrhage in
association with acute necrotizing encephalopathy has also been reported (Tanaka et al 2000). A recent analysis of
warfarin-related hemorrhage revealed that brainstem intracerebral hemorrhage may be more frequent (24.0% vs.
6.1%; P=0.005) with excessive anticoagulation (INR>3.0) compared with those in therapeutic range (Ma et al 2013).
Duret hemorrhages result secondary to increased intracranial hypertension more often after trauma and in
craniocerebral trauma victims with rapidly evolving descending transtentorial herniation. Duret hemorrhages are
typically located in the ventral and paramedian aspects of the upper brainstem (mesencephalon and pons). The
pathophysiology of Duret hemorrhage remains under debate: arterial origin (stretching and laceration of pontine
perforating branches of the basilar artery) versus venous origin (thrombosis and venous infarction). Multifactorial
causation seems likely (Parizel et al 2002).
In patients with small hemorrhages, investigations such as angiography and MRI, often fail to show an underlying
etiology. In the absence of any obvious etiology, telangiectasias or venous malformations are often proposed as the
lesions responsible for the hemorrhage. However, such lesions are rarely found during surgery or at autopsy. In
addition, because of their small size, they may be completely destroyed within the hematoma. Between
telangiectasias are commonly found incidentally at autopsy and seldom show signs of bleeding when examined at that
time, the relationship between such lesions and brainstem hemorrhage requires further study.
The most common cause of pontine hemorrhage is a rupture of the intraparenchymal branches of the basilar arteries.
Usually, the bleeding vessel is a perforator, and the hemorrhage is at its distal end (Dinsdale 1964). The hemorrhage
commonly occurs at the junction of the basis pontis and tegmentum. In a study, topographic correspondence has been
documented between hypertensive pontine microhemorrhages and larger primary pontine hemorrhages. This may
provide evidence that the 2 lesions share some etiologic basis (Jeong et al 2002). The hematoma may travel superiorly
into the midbrain or into the cerebellar peduncles but rarely extends into the medulla. Large hemorrhages frequently
rupture into the fourth ventricle (Dinsdale 1964). The presence of hemorrhage into the third ventricle is an
independent negative predictor of outcome (Staykov et al 2011).
Hypertensive patients develop fibrinoid necrosis or microaneurysms in the small arteries of the brainstem. Fibrinoid
necrosis results in segmental destruction of the vessel wall leading to arterial occlusion or rupture. Microaneurysms
are present in large numbers in the basal ganglion, thalamus, and pons. Cerebral hypertensive hemorrhage is frequent
in these regions of the brain. Such aneurysms are rarely seen in normotensive young individuals. Their numbers
increase with longstanding hypertension. In the series of Cole and Yates, microaneurysms were seen in 46% of
hypertensive patients and in 7% of normotensive patients (Cole and Yates 1967). None of the normotensive individuals

had brainstem lesions, whereas 15 lesions were present in the hypertensive individuals. A direct relationship between
the microaneurysms and hypertensive hemorrhage is difficult to establish. Perianeurysmal hemorrhage is
demonstrated occasionally, suggesting a possible relationship to a large hemorrhage. Usually the hemorrhage is
extensive, and the microaneurysm may be destroyed during the event.
The relationship between preexisting ischemic infarction and brainstem hemorrhage (ie, hemorrhagic infarction vs.
true primary hematoma) has remained a subject of controversy and may occasionally be difficult to distinguish (Haines
and Molman 1993); however, in most patients the differentiation is easy. Distinction between a diffuse widespread
hemorrhage and a subependymal hematoma has also been promoted by advocates of early surgery in brainstem
hematomas. Diffuse deep hemorrhages are seen in individuals with uncontrolled hypertension and are difficult to treat
surgically. Subependymal hematoma may result from rupture of vascular malformations. Patients with the latter
lesions have milder symptoms and may do well with surgical evacuation of the blood (Mangiardi and Epstein 1988).

Epidemiology"
There are little prospective data on the frequency of brainstem hemorrhage. Pre-CT studies estimated the incidence to
be 6% of brain hemorrhages (Haines and Molman 1993). The low incidence reflected only the inclusion of patients with
severe disease. Studies in the last 2 decades, with wider CT use, report a higher incidence of 13% to 22%. There are
no comparative series for the incidence of hemorrhage in the midbrain or the medulla (Haines and Molman 1993).

Prevention
Early and effective therapy of hypertension is the best way to prevent fibrinoid necrosis or formation of
microaneurysms. Surgical resection or embolization of arteriovenous malformations may prevent subsequent
hemorrhages.
Small vascular malformations are commonly seen at autopsy. MRI technology has made the diagnosis easier as such
lesions may be associated with small, old hemorrhages. For acute hemorrhage, CT scan is considered better than MRI,
but the literature indicates that MRI can identify hyperacute hemorrhages within 2 hours (Linfante et al 1999). Also,
MRI has been shown to be effective for the detection of old lacunar hemorrhage (Kinoshita et al 2000). The "cryptic"
malformations are being diagnosed with greater frequency. It is not known if treatment of such lesions will decrease
the incidence of smaller subependymal hemorrhages.

Differential diagnosis
The classical presentation with rapid loss of consciousness, pinpoint pupils, and hyperthermia in a hypertensive
individual is recognized easily as secondary to a large pontine hemorrhage. Rarely, a "locked-in" syndrome from
basilar artery occlusion may produce a similar picture. Smaller hemorrhages may cause no headache and mild
symptoms. These are difficult to separate clinically from an infarction in the pons or in other brainstem regions. In
patients with progressive symptoms, brain tumors may be suspected. Investigations, including a contrast-infused CT,
MRI, and angiography may be needed to rule out brainstem infarction, tumors, or arteriovenous malformations. It
should be noted that for diagnosis of acute hemorrhage, CT scan is usually sufficient.

Diagnostic workup
Patients presenting with brainstem hemorrhage, especially in the pons, need urgent evaluation of the pulmonary
status, as they may be at risk for aspiration or respiratory arrest. Blood pressure and cardiac dysfunction should be
monitored continuously and may require urgent attention. Investigation of the cause of hypertension sometimes
requires the assistance of a general internist.
Neurologically, the initial investigation is a CT scan of the head to localize the lesion and estimate its size. Cranial CT
scan and MRI remain the most important tools for diagnosis. A high attenuation mass localized to the brainstem with
densitometry consistent with blood is typical of hemorrhage. Gradual resolution with repeated CT examination is
typical. MRI is helpful in size estimation of the hemorrhage in sagittal views. Signs of smaller previous hemorrhage
may also be demonstrated on MRI. Follow-up CT scanning with contrast may reveal a vascular malformation or
underlying tumor. If an aneurysm or vascular malformation is suspected, cerebral angiography may be necessary.
Extension of the hemorrhage or edema may produce further compromise, resulting in deterioration of the clinical
status, which may require repeated scanning. Follow-up scan is recommended 4 weeks to 6 weeks after the ictal

event.
Although CT scans immediately become positive after a hemorrhage, MRI is useful in determining the etiology of the
hemorrhage (Meyer and Gorey 1998). The characteristic morphology of various types of lesions, including the so-called
"cryptic" malformation has become relatively easy to diagnosis with MRI. Multiple hemorrhages of various ages may be
seen in vascular malformations. MRI is also useful to differentiate between acute hemorrhage (intracellular
deoxyhemoglobin), subacute hemorrhage (intracellular and free methemoglobin), and chronic hemorrhage
(hemosiderin) (Felber et al 1999). Felber reported that MRI could reliably identify hematomas at various stages, but for
the hyperacute hemorrhage, CT is the investigation of choice.
Cerebral angiography is rarely necessary in most patients with cerebral hemorrhage as the diagnostic yield is usually
low with the test. The test should be ordered only if an arteriovenous malformation or an aneurysm is suspected to be
the underlying vascular pathology (Zhu et al 1997). In a series of 206 patients with cerebral hemorrhage where
cerebral angiography was done, the diagnostic yield was higher in younger patients (younger than 45 years of age)
and in those with no preexisting hypertension (Zhu et al 1997).
An electroencephalogram is usually not required as the diagnosis is easy and confirmed by CT.
Electroencephalography would show nonspecific slowing in most patients with drowsiness. Alpha-pattern coma has
also been described with brainstem hemorrhage (Hayashi et al 1996).

Management
All patients require hospital admission. Blood pressure, cardiac status, and respiratory status require careful
monitoring in the early days after the hemorrhage. If there are signs of cerebral edema, the patient may require
antiedema measures (eg, steroids, mannitol, or hyperventilation). Although medical treatments are limited, hematoma
expansion has been limited in a few cases treated with recombinant factor VIIa, including a pontine hemorrhage
(Meenakshi-Sundaram et al 2008). Ongoing research in animal models of acute intracerebral hemorrhage may
translate into clinical advances in years to come (Frantzias et al 2011).
Surgical intervention has been used (sometimes with dramatic results) in occasional patients. It can be recommended
only for centers with special expertise in this type of surgery. The indications for surgical therapy versus conservative
management were compared. In 127 patients with pontine hemorrhage reported until mid-1993, 49 patients were
treated surgically. In general, younger patients with slowly progressive disease and normal blood pressure were more
often surgically treated. Younger patients harboring more spherical arteriovenous malformations in nontectal regions
are excellent candidates for radiosurgery and are associated with higher obliteration rates and lower complication
rates (Maruyama et al 2004). Overall, brainstem hemorrhages due to occult vascular lesions have higher complication
rates when compared with other lesion sites (Pham et al 2009; Dammann et al 2011). Smaller subependymal lesions
that produce focal lesions with no intraventricular extension of blood may be more amenable to surgery. Surgical
approaches are midline, lateral, and through the fourth ventricle. The most common surgical approach is a posterior
one through the inferior vermis (Mangiardi and Epstein 1988; Haines and Molman 1993). This exposes the floor of the
fourth ventricle and facilitates drainage of the hematoma. Surgery is not indicated in patients with large diffuse
hemorrhage or in comatose patients (Nussbaum et al 1995). Acquired pendular nystagmus after pontine hemorrhage
has been reported to respond favorably to clonazepam (Yokota et al 1999).

Special considerations
Pregnancy
Although pregnancy can increase the risk of hemorrhage from an aneurysm or arteriovenous malformation (Jeffreys
1975), an increased incidence of brainstem hemorrhage has not been reported.
Anesthesia
There is no published information on this subject. Patients with brainstem hemorrhage may have a severe elevation of
blood pressure, an unprotected airway, and autonomic instability. This may increase the risk of anesthesia-related
complications.
Pediatric age group

Brainstem hemorrhage has been noted in children with traumatic brain injury. Clinical outcomes, however, may
include good neurologic outcomes (Beier and Dirks 2014).

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