What is the treatment for pontine and midbrain hemorrhage?

Treatment of Pontine and Midbrain Hemorrhage

The management of pontine and midbrain hemorrhage requires aggressive early care with focus on blood pressure control, airway management, ICP monitoring, and selective surgical intervention for certain cases, as most patients present with small hemorrhages that are potentially survivable with optimal medical care. 1

Initial Assessment and Management

• Rapid neuroimaging with CT or MRI is essential to diagnose pontine and midbrain hemorrhage, with CT being the gold standard for identifying acute hemorrhage 2
• Early deterioration is common in the first hours after onset, with over 20% of patients experiencing a decrease in Glasgow Coma Scale (GCS) of two or more points between prehospital assessment and emergency department evaluation 1
• Primary objectives in the prehospital setting include providing ventilatory and cardiovascular support and transporting the patient to the closest facility prepared to care for acute stroke patients 1

Medical Management

Blood Pressure Control

• Aggressive blood pressure management is recommended to prevent hematoma expansion in patients with intracerebral hemorrhage 2
• For patients with spontaneous intracerebral hemorrhage who present within 6 hours of symptom onset with systolic blood pressure >150 mmHg, blood pressure should be reduced if immediate surgery is not planned 1
• Maintain systolic blood pressure <160 mmHg for patients with unsecured aneurysms, while avoiding hypotension (systolic <110 mmHg) 1

Management of Increased Intracranial Pressure (ICP)

• For patients with evidence of increased ICP, the following measures should be implemented:
  • Elevation of the head of the bed to 30 degrees 1
  • Mannitol administration (0.25 to 2 g/kg body weight as a 15% to 25% solution over 30-60 minutes) to reduce intracranial pressure 3
  • Avoid hypotonic fluids; 0.9% saline is the recommended crystalloid solution in brain injury 1
  • Consider external ventricular drainage for hydrocephalus 4

Reversal of Coagulopathy

• For patients on anticoagulants with intracranial hemorrhage, immediate reversal of anticoagulation is critical 1
• For vitamin K antagonists (warfarin), administer four-factor prothrombin complex concentrate (PCC) and vitamin K 1
• For direct thrombin inhibitors (dabigatran), administer idarucizumab; if unavailable, consider hemodialysis 1
• For factor Xa inhibitors, administer four-factor PCC (50 U/kg) or activated PCC (50 U/kg) 1
• For heparin-associated bleeding, administer protamine sulfate at 1 mg for every 100 units of heparin given in the previous 2-3 hours (maximum single dose 50 mg) 1

Surgical Management

Indications for Surgical Intervention

• For most patients with pontine hemorrhage, the usefulness of surgery is uncertain 1
• Surgical evacuation should be considered for:
  • Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction 1, 2
  • Small, circumscribed pontine hemorrhages caused by vascular malformations may benefit from surgical removal 5, 6

Contraindications for Surgery

• Diffuse hypertensive pontine hemorrhages typically have poor outcomes with surgical intervention and are better managed medically 6
• Patients with extension of hemorrhage into the midbrain and thalamus, acute hydrocephalus, hyperthermia (>39°C), and tachycardia (>110 beats/min) have extremely poor prognosis 7

Prognostic Factors

• Poor prognostic factors include:

  • Coma on admission 7
  • Absent motor response 7
  • Absent corneal reflex or oculocephalic responses 7
  • Extension of hemorrhage into the midbrain and thalamus 7
  • Acute hydrocephalus on admission 7
  • Hyperthermia (>39°C) and tachycardia (>110 beats/min) 7

• Good prognostic factors include:

  • Alert status on admission 7
  • Small unilateral pontine hemorrhages 7
  • Dorsotegmental or hemipontine hemorrhages 5

Prevention of Secondary Complications

• Deep venous thrombosis prophylaxis with intermittent pneumatic compression should be initiated once bleeding has stabilized 2
• Monitor for and manage medical complications, including pneumonia, cardiac events, and acute kidney injury 2
• Provide appropriate rehabilitation for survivors, as improvement in neurological function can occur even in patients with severe deficits initially 8

Special Considerations

• Patients with pontine hemorrhage may develop cognitive dysfunction due to diaschisis (reduced activity in connected brain regions), requiring cognitive rehabilitation 8
• External ventricular drainage may be beneficial in controlling intracranial pressure in cases with intraventricular extension of hemorrhage 4
• Intensive care unit admission is recommended for close monitoring of vital signs and neurological status 1