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.
Abhijeet Deshmukh, MD
Thank you so much for your help. Your answer has been very useful.
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 ***@****.
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.
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?
i get it i had a pontene bleed myself