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Pontine Hemorrhage Recovery/Treatment
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Pontine Hemorrhage Recovery/Treatment

Hello,

I'm looking for a possible explanation of the condition and its treatment my 33 year old cousin is in. He has been hospitalized for over month in Bangladesh. It's been difficult to get accurate answers to our questions, so we're trying our best to find answers in the United States from the medical reports we've received. I've copied and pasted information regarding his condition below. It would be great if you could tell us anything regarding his state and possible treatments or recovery time.

Thank you for your time.
----

Here's a general overview of his condition from a report---
He is "non diabetic, non smoker, hypertensive, had a hemorrhagic stroke (pontine hemorrhage) on  March 23, 2009. At that time he was unconscious. He was treated conservatively in ICU and  HDU. Now patient is conscious, oriented but emotionally labile. His motor power is 2-3, tone increased. Deep tendon reflexes exaggerated. Sensory intact. Plantar reflex extensor bilaterally. There is retention  of urine. Patient is catheterized. But he is apparently better except fluctuation of blood pressure.”

Here's a timeline of his hospitalization --

#  Patient was found in his room in the state of unconscious, at 9-00 am on  date 24/03/09.  We guess that the patient got unconscious at about 11-00 pm, on 23/03/2009,   he was taken to the nearest hospital at 9-15 am on 24/3/2009

# Exact cause of unconsciousness is not clearly known. But the patient complained for bad headache, and high blood pressure.  

# The patient is not fully unconscious now, but can not communicate.

# He can not speak yet. He can hear. May be recognizing people.
  
# In the 1st MRI report of brain on 24-3-2009  the doctors opined “Features  are more in favour of  toxic demyelination involving the pons. DDX: Pontine infract. Mild cerebral cortical atrophy. Partially empty sella”.  

# In the 2nd  MRI report of brain the doctors opined “ Subacute pontine hematoma”.

# In the 3rd MRI report on 19-4-2009 the doctors opined “Late subacute hematoma at pons, with evidence of mild reduced in size of the hematoma since the MRI on date 05.04.2009”.
  
# At present the patient is getting antibiotic, with some other neurological medicine. If full description of the medicine the patient is getting right now is needed can be supplied with latter.

#  The patient is in Hospital. He need not any life support or, ventilation. Very recently the blood pressure of the patient is fluctuating.

# The patient can not move or walk,  he can  move a little his body, hands, legs,and neck.He tries to follow some commands, such as he can move his eyes up and down and not laterally, he tries to move his hand and neck as per the command of the doctor.

# The condition of the patient is improving very slowly.

# The patient was suffering from high blood pressure and bad headache since long.
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368886_tn?1278962315
Hello.

It is unfortunate that you cousin had to suffer from this condition at a young age.

Hypertension is the commonest cause of intraparenchymal hemorrhage (bleeding in the substance of the brain). Pontine Hemorrhage suggests that the bleed has occurred in Pons, a very important area as far as the brain functions are concerned. All the important nerve fibres that originate in the higher centers of the brain, travel in bundles, through Pons, onto the spinal cord and their respective destinations in all parts of the body. The reverse is also true (fibers traveling from the body to the brain centers). Hence, a bleed in pons affects the entire body. Apart from the partial or complete paralysis, the patient loses consciousness, has pin-point (1mm) sized pupils (the black in the eye),  amongst other features. The mechanism responsible for "doll-eye movements" is also impaired. This mean, the eyes do not move horizontally if the head is moved side to side. That explains why he can move the eyes vertically, but not horizontally.

CT scan is usually preferred to MRI in acute bleed. CT is more sensitive to acute blood colection that the routine MRI. But since your cousin was found unconscious the morning after, and we are not sure how much time elapsed after the actual hemorrhage, MRI looks appropriate.

It is necessary to see on MRI if there is any pressure effect due to the hematoma (blood collection). In some cases, the pressure effects may lead to obstruction of the normal flow of the cerebrospinal fluid, and the CSF pressure may increase, leading to further complications. It is usually not advised to do any lumbar puncture to drain the CSF, as it may increase the chances of further bleeding in the brain. Manuevers such as forced hyperventilation (increased rate of respiration) and certain medicines, help to reduce the increased CSF pressure.

One important fact to know in this case is that about 50% of persons suffering from an intraparenchymal hemorrhage die during such an episode.  Of the other 50% who survive the hemrrhage, most have fair to good recovery, depending upon various factors such as age, treatment, etc. Pontine Hemorrhage has better prognosis in younger patients. (Balci et al).  The volume of the hematoma also matters. Chances of recovery are better if the volume of the hematoma is somewhere near 3.3 ml. (Balci et al).

Treatment usually involves anti-hypertensives, medicnes to lower the intracranial pressure, antibiotics, multivitamins. Surgery in this case will not help much. Nothing much can be done once the hemorrhage has ocurred. After a few weeks to few months, the hematoma reduces in size gradually.

I may not be able to give you the exact probability of cure, but a lot will depend on how he takes care of the hypertension. Since he is only 33, he has much to look forward to. It will help immensely to make certain lifestyle changes to counter the hypertension. He will probably need antihypertensive medicine for a long time. Another fact to note is that the hematoma usually does not result in death of the brain tissue surrounding it. Hence, that area of the brain can resume functioning gradually. He will need physiotherapy and occupational therapy interventions.

Hope this information has helped you. And hope your cousin recovers soon.

Regards

Abhijeet Deshmukh, MD
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Avatar_f_tn
Thank you so much for your help. Your answer has been very useful.
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Please be advised that I represent a young man who also suffered a Pontine Hemorrhage after drinking a high caffeine energy drink.  Did your patient also consume a high energy caffeine drink.  If so, please contact me at ***@****.

Thank you
Catherine Hilton
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Avatar_m_tn
Dear Doc.,

Patient profile:

My Father-in-law, aged 68 yrs., hypertensive (with no critical cardiac ailment ever reported). He has been extremely fit and active throughout his life, used to walk long, dance as a part of senior citizen group, until on 6th Dec. 2013, afternoon when he suddenly complained of severe headache and then collapsed with mild paralytic condition.

Diagnosis: Pontine Hemorrhage in K/C/O hypertension.

Summary: Presented with episode of left sided weakness, left sided seizures, frothing from mouth, tongue bite f/b loss of consciousness on 6th Dec., was taken to the nearby nursing home in next 20 min. wherein a view of the unconsciousness and gasping breathing, he was intubated and put on mechanical ventilator. CT Brain with MR diffusion was s/o large pontine hemorrhage with extension into midbrain, 4th ventricle, IVH with cerebral atrophy, no hydrocephalus. On 6th Dec., the patient was transferred to bigger hospital for further management.
Neurologically GCS 3/15, doll's eye absent, corneal reflexes absent, lower limbs withdraws to local pain, pupils symmetrical (2 mm each), not reacting to light. Treated with anti-epilepsi medications, IV mannitol (Anti-oedema), ventilator support continued. Repeat CT Brain s/o temporal evolutions of pontine hematoma, with same mass effect with IVH. He was on lobet infusion for high BP, now on Amlodep. Tracheostomy was done and gradually weaned off from ventilator and now on T-piece, maintaining well. Neurologically, patient remain the same, has central fever, bromocriptine started, cultures reports did not show any growth till now, antibiotics continued. There is slight rise in creatinine (1.55), drug induced, hence Mannitol stopped.
At present, patient being managed conservatively, supportive care continues.
Query:
What are his chances of survival? Will he ever open his eyes, identify people, feel any emotions, will he hear anything and react? How long this situation may prolong?
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