Initial Management of Pontine Hemorrhage
Pontine hemorrhage requires immediate airway protection, blood pressure control targeting mean arterial pressure ≥80 mmHg if increased intracranial pressure is present, and intensive care monitoring, with surgical intervention reserved only for hydrocephalus management via external ventricular drainage. 1
Immediate Stabilization
Airway and Respiratory Management
- Secure the airway immediately in patients with decreased consciousness (Glasgow Coma Scale ≤8) to prevent aspiration, as these patients are at high risk for respiratory failure. 1
- Administer high-flow oxygen to all patients to maintain adequate oxygenation. 1
- Avoid hyperventilation and excessive positive end-expiratory pressure in severely compromised patients, as this can worsen cerebral perfusion. 2
Vascular Access and Monitoring
- Establish large-bore intravenous access, ideally 8-Fr central venous catheter, for rapid medication administration and fluid management. 2, 1
- Obtain baseline laboratory studies immediately: full blood count, prothrombin time, activated partial thromboplastin time, Clauss fibrinogen, and cross-match. 2, 1
- Consider viscoelastic testing (TEG or ROTEM) if available for real-time coagulation assessment. 2, 1
Blood Pressure Management
Target Parameters
- Maintain mean arterial pressure ≥80 mmHg if there is evidence of increased intracranial pressure to ensure adequate cerebral perfusion. 1
- Avoid aggressive normalization of blood pressure initially, but ensure adequate organ perfusion. 1
- Avoid vasopressors during the acute phase unless absolutely necessary, as they can worsen outcomes. 2, 1
Critical Caveat
The trauma guidelines' recommendation of systolic blood pressure 80-100 mmHg applies only to trauma without brain injury and should NOT be applied to pontine hemorrhage. 2
Temperature Management
- Actively warm hypothermic patients and maintain normothermia, as hyperthermia (core temperature >39°C) is associated with mortality in pontine hemorrhage. 1, 3
- Monitor core temperature continuously, as hyperthermia is observed only in patients who die from pontine hemorrhage. 3
Neurological Assessment and Prognostication
Poor Prognostic Indicators
The following features predict mortality and should guide intensity of care decisions:
- Coma on admission is the single most predictive clinical feature of death. 4, 3
- Large paramedian hemorrhage type on CT imaging. 4
- Transverse hematoma diameter ≥20 mm on CT. 4
- Absent corneal reflex or oculocephalic responses. 3
- Extension into midbrain and thalamus on CT. 3
- Acute hydrocephalus on admission CT. 3
- Tachycardia >110 beats/min. 3
When all three features are present (coma, large paramedian hemorrhage, diameter ≥20 mm), survival is extremely unlikely. 4
Favorable Prognostic Indicators
- Alert mental status on admission. 3
- Small unilateral pontine hemorrhage. 3
- Lateral tegmental hemorrhage type. 4
- Dorsotegmental or hemipontine hemorrhages (as opposed to centro-paramedian). 5
Surgical Considerations
Indications for Surgery
- External ventricular drainage is indicated for acute hydrocephalus to control intracranial pressure. 6
- Direct surgical evacuation of pontine hemorrhage is generally not recommended according to current practice, as most patients are managed conservatively. 7
Exception
In rare cases with arteriovenous malformations or cavernous angiomas causing the hemorrhage, surgical removal may be considered. 5
Intensive Care Management
Critical Care Admission
- All patients should be admitted to intensive care for continuous monitoring of vital signs, neurological status, coagulation parameters, hemoglobin, and blood gases. 2, 1
- Monitor for signs of rebleeding through serial neurological examinations and imaging if clinical deterioration occurs. 2
Coagulopathy Management
- Anticipate and aggressively treat coagulopathy if present, particularly in patients on anticoagulants (a known risk factor for pontine hemorrhage). 2, 5
- Correct any identified coagulation abnormalities promptly. 2
Post-Acute Management
Venous Thromboprophylaxis
- Initiate standard venous thromboprophylaxis as soon as bleeding is stabilized, as patients rapidly develop a prothrombotic state after the acute hemorrhage phase. 2, 1
- This typically occurs within 24-48 hours after hemorrhage stabilization is confirmed. 2
Important Contraindications
Nimodipine
Do NOT administer nimodipine for pontine hemorrhage. 8 Nimodipine is indicated only for subarachnoid hemorrhage to prevent vasospasm, not for intraparenchymal hemorrhages like pontine hemorrhage. The drug label explicitly warns against intravenous administration and its use is specific to SAH patients. 8
Key Clinical Pitfall
The most common error is applying trauma hemorrhage protocols to pontine hemorrhage patients. Unlike trauma patients without brain injury, pontine hemorrhage patients require higher blood pressure targets to maintain cerebral perfusion pressure, particularly when intracranial pressure is elevated. 2, 1