Treatment of Pons Stroke
Patients with pons stroke should be immediately admitted to a specialized stroke unit for multidisciplinary care, which significantly reduces mortality and disability compared to management in general wards. 1
Initial Assessment and Stabilization
- Rapidly assess airway, breathing, and circulation
- Secure airway patency; consider intubation if respiratory insufficiency develops 1
- Establish IV access and initiate cardiac monitoring 1
- Perform immediate neuroimaging:
- Non-contrast CT brain to rule out hemorrhage
- CT angiography to assess basilar artery and branch occlusion 2
Acute Management
Blood Pressure Management
- For patients eligible for thrombolysis:
- Maintain BP <185/110 mmHg before treatment
- Maintain BP <180/105 mmHg for 24 hours after treatment 1
- For patients not eligible for thrombolysis:
Reperfusion Therapy
- Evaluate eligibility for IV thrombolysis if within 4.5 hours of symptom onset 2
- Consider endovascular thrombectomy if large vessel occlusion (basilar artery) is identified and can be treated within 24 hours of symptom onset 1
Management of Cerebral Edema
- Monitor for signs of neurological deterioration:
- Decreased level of consciousness
- Worsening neurological deficits
- Pupillary changes
- Changes in respiratory status 1
- For massive pontine infarction with hydrocephalus, consider ventriculostomy 1
- For cerebellar infarction with brainstem compression, consider decompressive suboccipital craniectomy 1
Ongoing Care in Stroke Unit
Neurological Monitoring
- Perform frequent neurological assessments using standardized stroke scales 1
- Monitor for seizures but only treat documented seizures (prophylactic anticonvulsants not recommended) 1
Prevention of Complications
Deep Vein Thrombosis Prevention
- Implement early mobilization when appropriate 1
- Use intermittent pneumatic compression devices 1
- Consider anticoagulants for high-risk immobile patients 1
Dysphagia Management
- Keep patient NPO until dysphagia screening completed (within 4-24 hours) 1
- If screening fails, obtain formal swallowing assessment by speech-language pathologist 1
- Consider nasogastric or PEG feeding for patients who cannot take oral nutrition 1
Temperature Management
- Maintain normothermia; treat fever (>38°C) aggressively 1
- Monitor for pneumonia, especially in patients with dysphagia 1
Bladder Management
- Avoid indwelling urinary catheters when possible 1
- Monitor for urinary retention, especially in first 72 hours 1
- Consider intermittent catheterization if post-void residual >100 mL 1
Secondary Prevention
- Initiate aspirin (160-300 mg) within 24-48 hours of ischemic stroke onset 1
- Address modifiable risk factors (hypertension, diabetes, smoking, hyperlipidemia) 2
Special Considerations for Pontine Strokes
- Lower pontine infarctions are associated with higher risk of neurological deterioration 4
- Basilar artery branch disease is a predictor of neurological deterioration in pontine strokes 4
- Blood pressure fluctuations may correlate with neurological worsening in pontine warning syndrome 3
Early Rehabilitation
- Begin rehabilitation as soon as the patient is medically stable 1
- Include physiotherapy, occupational therapy, and speech therapy as needed 1
- Set person-centered, collaborative goals with patients and families 1
Pitfalls to Avoid
- Don't delay neuroimaging for non-urgent tests
- Don't wait for laboratory results before initiating thrombolysis unless specific concerns exist
- Don't delay transfer to a specialized stroke center if advanced care is needed
- Don't start intensive out-of-bed activities within 24 hours of stroke onset 1
- Don't administer prophylactic antiseizure medications 1
Pontine strokes require vigilant monitoring due to their proximity to vital brainstem structures. The prognosis varies widely depending on the extent and location of the infarct, with lower pontine lesions typically carrying a higher risk of deterioration.