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ABSTRACT
Introduction.Stroke is a major public health problem in the world in terms of morbidity and mortality. According to Collomb, spontaneous hemorrhages of the brainstem represent between 2 to 16% of hemorrhagic strokes [1]. Spontaneous hemorrhages of the brainstem due to their location are often life-threatening for patients. The aim of this study is to determine the epidemiological, clinical and radiological aspects of spontaneous hemorrhages of brainstem. Patients and methods. This was a prospective and descriptive study from January 2016 to September 2018 of cases of spontaneous haemorrhages of the brainstem collected in the neurology department of Point G Teaching Hospital. Patients male or female were included in the study wich having presented a spontaneous hemorrhage in the brainstem certified by cerebral imaging. Cases of post-traumatic brainstem hemorrhage and cerebral or cerebellar hemorrhages with brainstem contamination were not included. Results. The frequency of brainstem haemorrhages was 5.2% of haemorrhagic strokes with a predominance of women (sex-ratio 1.5). The average age was 41.4 years with extremes of 27 and 52 years. High blood pressure (HBP) was the major cardiovascular risk factor in 90% of cases. The site of the hematoma was pons in 90% of cases. The outcome was favorable in all of ours patients. Conclusion. Spontaneous haemorrhage of brainstem is a serious and potentially fatal condition for which hospitalization in a neurovascular unit is required in the face of signs of seriousness (volume of bleeding, deep coma, cardio-respiratory distress, epilepticus state, etc.). The finesse of the neurological examination makes it possible to suspect the level of the lesion on the brainstem. Unlike ischemias, cerebral CT is very sensitive in detecting hemorrhages from TC. Observation of directives recommending symptomatic treatment combined with monitoring. Gave us a favorable outcome in all of our patients despite our limited resources.
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References
- Collomb H, Dumas M, Girard P.L, Lemercier G TD. Hémorragies primitives du tronc cerebral. Etude anatomique et clinique de 36 cas. Rev Neurol 1973 ; 129 : 185-210.
- Bogousslavsky J, Bousser MG, MAS JL. Accidents vasculaires cérébraux. Paris : DOIN Éditeurs ; 1993.
- Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al. American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Peripheral Vascular Disease; Council on Nutrition, Physical Activity and Metabolism. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(7):2064–89.
- Wang SS, Yang Y, Velz J, Keller E, et al. Management of brainstem hemrraghes. Swiss Med Wkly. 2019;149p.
- Dinsdale HB. Spontaneous hemorrhage in the posterior fossa. A study of primary cerebellar and pontine hemorrhages with observations on their pathogenesis. Arch Neurol. 1964;10(2):200–17.
- Van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol. 2010;9(2):167–76.
- Chung CS, Park CH. Primary pontine hemorrhage: a new CT classification. Neurology. 1992;42(4):830–4.
- Raison J.S, Bourbotte G , Baum T.P, Pagès M Hemorragies spontanees du tronc cerebral :etude retrospective de 25 observations. Rev Neurol mars 2008 ; Vol 164-N03 :225-32.
- Louis J, Delgado D, Luis D, Chillet P, Vadot W. Les accidents vasculaires cérébraux du tronc cérébral. Urgences 2009 : 79-91.
- Muler R, Pfefferkom T, Vatenkhab et al. Admission facility is associated with outcome of basilar artery occlusion. Stroke 2007 ; 38 (4) :1380-3.
- Takeuchi S, Suzuki G, Takasato Y, Masaoka H et al. Prognostic factors in patients with primary brainstem hemorrhage. Clin Neurol Neurosurg. 2013 Jun;115 (6):732-5.
- Collège des enseignanants de neurologie. Elsevier/ Masson 4e édition 2016 : 561 p.
- Zelia K Chiu 1 , Iwan E Bennett 2 , Patrick Chan 3 , Jeffrey V Rosenfeld . Methamphetamine-related brainstem haemorrhage. J Clin Neurosci . 2016 Oct;32:137-9.
- Martin-Schild S, Albright KC, Hallevi H, Barreto AD, Philip M, Misra V, et al. Intracerebral hemorrhage in cocaine users. Stroke. 2010;41(4):680–4.
- Levy R. État confusionnel et trouble de conscience. Rev Prat 2002 ; 52 : 901-8.
- Rohde V , Berns E, Rohde I, Gilsbach JM, Ryang YM. Experiences in the management of brainstem hematomas. Neurosurg Rev. 2007 Jul;30 (3):219-23; discussion 223-4.
- Link MJ, Bartleson JD, Forbes G, Meyer FB. Spontaneous midbrain hemorrhage: report of seven new cases. Surg Neurol. 1993 Jan; 39(1):58-65.
- Kidwell CS, Chalela JA, Saver JL, Starkman S, Hill MD, Demchuk AM, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004;292(15):1823–30.
- Dziewas R, Kremer M, Lüdemann P, Nabavi DG, Dräger B, Ringelstein B. The prognostic impact of clinical and CT parameters in patients with pontine hemorrhage. Cerebrovasc Dis. 2003;16(3):224–9.
- Balci K, Asil T, Kerimoglu M, Celik Y, Utku U. Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage. Clin Neurol Neurosurg. 2005;108(1):36–9.
- Bewermeyer H, Neveling M, Ebhardt G, Heiss WD. Hémorragies spontanées du tronc cérébral. Fortschr Neurol Psychiatr . 1984 Aug: 52(8):259-76.
- Boudouresques.G, Hauw.JJ ER. Etude anatomique de 318 hémorragies intra parenchymateuses de l’adulte. Rev Neurol 1979 ; 135 : 845-65.
- Mangiardi.J. R, Epstein.F.J. Brainstem haematomas : review of the literature and presentation of five news cases. J Neurol Neurosurg Psychiatry 1988; 51: 966-76.
- Wessels T, Möller-Hartmann W, Noth J, Klötzsch C. CT findings and clinical features as markers for patient outcome in primary pontine hemorrhage. AJNR Am J Neuroradiol. 2004;25(2):257–60.
- Bozinov O, Hatano T, Sarnthein J, Burkhardt JK, Bertalanffy H. Current clinical management of brainstem cavernomas. Swiss Med Wkly. 2010;140.
- Yamamura K, Sumioka S, Nakamura S. Relationship between the clinical manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. J Neurol Sci. 1999;167(2):107–11.
- Thiam.A, Ndiaye, Ndiaye. Ng, Ndiaye.I.P. Hémtome pédonculaire benin : A propos de deux cas révélés par la Tomodensitométrie (TDM). Médecine d'Afrique Noire : 2000, 47 (12).
- Nilsson OG, Lindgren A, Brandt L, Säveland H. Prediction of death in patients with primary intracerebral hemorrhage: a prospective study of a defined population. J Neurosurg. 2002;97(3):531–6.
- Murata Y, Yamaguchi S, Kajikawa H, et al. Relationship between the clinical manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. Journal of the Neurological Sciences Volume 167, Issue 2, 15 August 1999, Pages 107-11.
- Russell B, Rengachary SS, McGregor D. Primary pontine hematoma presenting as a cerebellopontine angle mass. Neurosurgery.1986;19(1):129–33.
- Ye Z, Huang X, Han Z, Shao B, Cheng J, Wang Z, et al. Three-year prognosis of first-ever primary pontine hemorrhage in a hospital-based registry. J Clin Neurosci. 2015;22(7):1133–8.
- Matsukawa H, Shinoda M, Fujii M, Takahashi O, Murakata A. Risk factors for mortality in patients with non-traumatic pontine hemorrhage. Acta Neurol Scand. 2015;131(4):240–5.
- Jang JH, Song YG, Kim YZ. Predictors of 30-day mortality and 90-day functional recovery after primary pontine hemorrhage. J Korean Med Sci. 2011;26(1):100–7.
- Choi JH, Mast H, Sciacca RR, Hartmann A, Khaw AV, Mohr JP, et al. Clinical outcome after first and recurrent hemorrhage in patients with untreated brain arteriovenous malformation. Stroke. 2006;37(5): 1243–7.
- Fong C. Factors affecting the outcome in pontine hemorrhage. Acta Neurol Taiwan. 1999;8:6–11.
- Wijdicks EF, St Louis E. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology. 1997;49(5):1342–6.
- Deletis V, Sala F. Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol. 2008;119(2):248–64.
- Deletis V, Fernández-Conejero I. Intraoperative monitoring and mapping of the functional integrity of the brainstem. J Clin Neurol. 2016;12(3):262–73.
- Hemphill JC, 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032–60.
- Schwarz S, Häfner K, Aschoff A, Schwab S. Incidence and prognostic significance of fever following intracerebral hemorrhage. Neurology. 2000;54(2):354–61.
- Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, et al.; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–65.
- Boulouis G, Morotti A, Goldstein JN, Charidimou A. Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and metaanalysis of randomised trials. J Neurol Neurosurg Psychiatry. 2017;88(4):339–45.
References
Collomb H, Dumas M, Girard P.L, Lemercier G TD. Hémorragies primitives du tronc cerebral. Etude anatomique et clinique de 36 cas. Rev Neurol 1973 ; 129 : 185-210.
Bogousslavsky J, Bousser MG, MAS JL. Accidents vasculaires cérébraux. Paris : DOIN Éditeurs ; 1993.
Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al. American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Peripheral Vascular Disease; Council on Nutrition, Physical Activity and Metabolism. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(7):2064–89.
Wang SS, Yang Y, Velz J, Keller E, et al. Management of brainstem hemrraghes. Swiss Med Wkly. 2019;149p.
Dinsdale HB. Spontaneous hemorrhage in the posterior fossa. A study of primary cerebellar and pontine hemorrhages with observations on their pathogenesis. Arch Neurol. 1964;10(2):200–17.
Van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol. 2010;9(2):167–76.
Chung CS, Park CH. Primary pontine hemorrhage: a new CT classification. Neurology. 1992;42(4):830–4.
Raison J.S, Bourbotte G , Baum T.P, Pagès M Hemorragies spontanees du tronc cerebral :etude retrospective de 25 observations. Rev Neurol mars 2008 ; Vol 164-N03 :225-32.
Louis J, Delgado D, Luis D, Chillet P, Vadot W. Les accidents vasculaires cérébraux du tronc cérébral. Urgences 2009 : 79-91.
Muler R, Pfefferkom T, Vatenkhab et al. Admission facility is associated with outcome of basilar artery occlusion. Stroke 2007 ; 38 (4) :1380-3.
Takeuchi S, Suzuki G, Takasato Y, Masaoka H et al. Prognostic factors in patients with primary brainstem hemorrhage. Clin Neurol Neurosurg. 2013 Jun;115 (6):732-5.
Collège des enseignanants de neurologie. Elsevier/ Masson 4e édition 2016 : 561 p.
Zelia K Chiu 1 , Iwan E Bennett 2 , Patrick Chan 3 , Jeffrey V Rosenfeld . Methamphetamine-related brainstem haemorrhage. J Clin Neurosci . 2016 Oct;32:137-9.
Martin-Schild S, Albright KC, Hallevi H, Barreto AD, Philip M, Misra V, et al. Intracerebral hemorrhage in cocaine users. Stroke. 2010;41(4):680–4.
Levy R. État confusionnel et trouble de conscience. Rev Prat 2002 ; 52 : 901-8.
Rohde V , Berns E, Rohde I, Gilsbach JM, Ryang YM. Experiences in the management of brainstem hematomas. Neurosurg Rev. 2007 Jul;30 (3):219-23; discussion 223-4.
Link MJ, Bartleson JD, Forbes G, Meyer FB. Spontaneous midbrain hemorrhage: report of seven new cases. Surg Neurol. 1993 Jan; 39(1):58-65.
Kidwell CS, Chalela JA, Saver JL, Starkman S, Hill MD, Demchuk AM, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004;292(15):1823–30.
Dziewas R, Kremer M, Lüdemann P, Nabavi DG, Dräger B, Ringelstein B. The prognostic impact of clinical and CT parameters in patients with pontine hemorrhage. Cerebrovasc Dis. 2003;16(3):224–9.
Balci K, Asil T, Kerimoglu M, Celik Y, Utku U. Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage. Clin Neurol Neurosurg. 2005;108(1):36–9.
Bewermeyer H, Neveling M, Ebhardt G, Heiss WD. Hémorragies spontanées du tronc cérébral. Fortschr Neurol Psychiatr . 1984 Aug: 52(8):259-76.
Boudouresques.G, Hauw.JJ ER. Etude anatomique de 318 hémorragies intra parenchymateuses de l’adulte. Rev Neurol 1979 ; 135 : 845-65.
Mangiardi.J. R, Epstein.F.J. Brainstem haematomas : review of the literature and presentation of five news cases. J Neurol Neurosurg Psychiatry 1988; 51: 966-76.
Wessels T, Möller-Hartmann W, Noth J, Klötzsch C. CT findings and clinical features as markers for patient outcome in primary pontine hemorrhage. AJNR Am J Neuroradiol. 2004;25(2):257–60.
Bozinov O, Hatano T, Sarnthein J, Burkhardt JK, Bertalanffy H. Current clinical management of brainstem cavernomas. Swiss Med Wkly. 2010;140.
Yamamura K, Sumioka S, Nakamura S. Relationship between the clinical manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. J Neurol Sci. 1999;167(2):107–11.
Thiam.A, Ndiaye, Ndiaye. Ng, Ndiaye.I.P. Hémtome pédonculaire benin : A propos de deux cas révélés par la Tomodensitométrie (TDM). Médecine d'Afrique Noire : 2000, 47 (12).
Nilsson OG, Lindgren A, Brandt L, Säveland H. Prediction of death in patients with primary intracerebral hemorrhage: a prospective study of a defined population. J Neurosurg. 2002;97(3):531–6.
Murata Y, Yamaguchi S, Kajikawa H, et al. Relationship between the clinical manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. Journal of the Neurological Sciences Volume 167, Issue 2, 15 August 1999, Pages 107-11.
Russell B, Rengachary SS, McGregor D. Primary pontine hematoma presenting as a cerebellopontine angle mass. Neurosurgery.1986;19(1):129–33.
Ye Z, Huang X, Han Z, Shao B, Cheng J, Wang Z, et al. Three-year prognosis of first-ever primary pontine hemorrhage in a hospital-based registry. J Clin Neurosci. 2015;22(7):1133–8.
Matsukawa H, Shinoda M, Fujii M, Takahashi O, Murakata A. Risk factors for mortality in patients with non-traumatic pontine hemorrhage. Acta Neurol Scand. 2015;131(4):240–5.
Jang JH, Song YG, Kim YZ. Predictors of 30-day mortality and 90-day functional recovery after primary pontine hemorrhage. J Korean Med Sci. 2011;26(1):100–7.
Choi JH, Mast H, Sciacca RR, Hartmann A, Khaw AV, Mohr JP, et al. Clinical outcome after first and recurrent hemorrhage in patients with untreated brain arteriovenous malformation. Stroke. 2006;37(5): 1243–7.
Fong C. Factors affecting the outcome in pontine hemorrhage. Acta Neurol Taiwan. 1999;8:6–11.
Wijdicks EF, St Louis E. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology. 1997;49(5):1342–6.
Deletis V, Sala F. Intraoperative neurophysiological monitoring of the spinal cord during spinal cord and spine surgery: a review focus on the corticospinal tracts. Clin Neurophysiol. 2008;119(2):248–64.
Deletis V, Fernández-Conejero I. Intraoperative monitoring and mapping of the functional integrity of the brainstem. J Clin Neurol. 2016;12(3):262–73.
Hemphill JC, 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032–60.
Schwarz S, Häfner K, Aschoff A, Schwab S. Incidence and prognostic significance of fever following intracerebral hemorrhage. Neurology. 2000;54(2):354–61.
Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, et al.; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–65.
Boulouis G, Morotti A, Goldstein JN, Charidimou A. Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and metaanalysis of randomised trials. J Neurol Neurosurg Psychiatry. 2017;88(4):339–45.