What are the symptoms of bleeding in the brainstem?

Symptoms of Brainstem Hemorrhage

Brainstem hemorrhage presents with a constellation of symptoms including sudden severe headache, loss of consciousness, cranial nerve deficits, contralateral motor and sensory deficits (crossed brainstem syndrome), and signs of impending brainstem compression such as progressive reduction of consciousness, hypertension, and bradycardia. 1, 2

Core Clinical Presentations

Acute Symptoms at Onset

• Headache is the most frequent presenting symptom, occurring in approximately 70% of patients, typically described as sudden and severe 2
• Loss of consciousness occurs in 50% of patients at presentation 2
• Unilateral weakness (hemiparesis) is present in 60% of cases 2
• Nausea and vomiting frequently accompany the headache 1

Crossed Brainstem Syndrome Pattern

The hallmark of brainstem hemorrhage is the crossed brainstem syndrome, which combines ipsilateral cranial nerve deficits with contralateral long tract signs. 3 This distinctive pattern includes:

• Ipsilateral cranial nerve palsies (facial weakness, diplopia, abducens nerve palsy) 1, 3
• Contralateral hemiparesis or hemiplegia 3
• Contralateral hemisensory deficits 3, 4

Progressive Neurological Deterioration

Signs of impending brainstem compression are life-threatening and appear late before herniation: 1

• Progressive reduction of consciousness leading to stupor or coma 1
• Hypertension and bradycardia (Cushing's triad) 1
• Sudden respiratory arrest can occur, particularly with medullary involvement 5

Additional Neurological Manifestations

• Ataxia (progressive cerebellar signs) 1
• Pyramidal signs (spasticity, hyperreflexia) 1, 4
• Diplopia and other cranial nerve palsies 1
• Chorea or athetosis (movement disorders) 4
• Psychotic symptoms may rarely occur, particularly with pontine and mesencephalic involvement 6

Location-Specific Symptoms

Pontine Hemorrhage (Most Common Site)

• Pontine hemorrhage is the most frequent location, present in all patients in one series 2
• Locked-in syndrome can develop with extensive pontine involvement 6
• Concomitant cerebellar hemorrhage occurs in 50% of pontine cases 2

Medullary Hemorrhage

• High risk for aspiration due to lower cranial nerve involvement 5
• Sudden respiratory arrest is a critical risk requiring careful observation 5

Prognostic Indicators

Glasgow Coma Scale (GCS) >8 at presentation is associated with good outcomes at three months (p=0.03). 2 Conversely:

• Low GCS at presentation predicts poor outcomes 2
• Brainstem hemorrhage carries high morbidity and mortality with mean ICU stay of 17 days and hospital stay of 58 days 2
• At discharge, only 30% achieve functional independence (mRS 0-2), while 20% die 2

Critical Clinical Pitfalls

The most important pitfall is that patients with medullary hemorrhage require intensive monitoring as they can suddenly develop respiratory arrest without warning. 5 Additionally:

• Small brainstem hemorrhages may have excellent recovery potential, so aggressive early intervention should not be dismissed 5
• Diagnosis may be unsuspected until CT imaging is performed, as symptoms can mimic other conditions 5
• Recurrent hemorrhages are rare after initial bleeding, particularly in small hemorrhages 5