Clinical Case Report Medicine ®

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Surgical treatment of spontaneous brainstem

hemorrhage
A case report
∗
Guangshan Hao, MD, Zhentao Xu, MD, Jianxin Zhu, MD

Abstract
Rationale The improvement of microneurosurgery and neuroimaging, as well as neuronavigation and neurophysiological
monitoring, enables neurosurgeons to safely and accurately resect lesions on the brainstem.
Patient concerns A 54-year-old man, with 2-year history of hypertension, presented with sudden loss of consciousness for 1.5
hours.
Diagnoses Spontaneous brainstem hemorrhage.
Interventions We performed posterior fossa decompression together with hematoma evacuation in the super early stage for the
patient.
Outcomes The patient regained normal spontaneous breathing function after surgery. And he needed help for daily activities with
hemiplegia of right limb at three-month follow-up.
Lessons The hematoma evacuation together with posterior fossa decompression in the super early stage maybe a good treatment
for patients in a deep coma with a large hematoma at the dorsal side.
Abbreviations: CT = computed tomography, GCS = Glasgow coma scale.
Keywords: massive, microneurosurgery, spontaneous brainstem hemorrhage

1. Introduction treatment of brainstem hemorrhage easier and safer. Moreover,

with the development of neurological intensive care, neural stem
Hemorrhage on the brainstem, which is regarded as the vital
cells and rehabilitation, survivors will expect a better prognosis.
center of the body, has always been a difficult clinical problem
However, there are currently few reports on the surgical
due to its high mortality. The most common of these is pontine
treatment of spontaneous brainstem hemorrhage and no
hemorrhage, with an incidence of 6% to 7% and a mortality up
standardized guidelines. Here we report one case of patient
to 40% to 50%.[1,2] With the development of microneurosur-
with severe spontaneous brainstem hemorrhage who underwent
gery, doctors have tried surgical treatments for brainstem
surgical treatment.
hemorrhage. Brainstem hemorrhages secondary to cavernous
malformations are much more benign and patients can get a good
prognosis through microneurosurgery treatment.[3] Instead, the 2. Case presentation
surgical treatment of spontaneous brainstem hemorrhage is still A 54-year-old man, with 2-year history of hypertension, presented
controversial with pro and con.[4–7] The ongoing continuous with sudden loss of consciousness for 1.5 hours. On his arrival to
developments of microsurgical techniques, intraoperative neuro- hospital, he was in a deep coma (Glasgow Coma Scale (GCS) of 3)
physiological monitoring, and neuronavigation make surgical with unstable vital signs (Respiratory Rate: 3bpm, Blood Pressure:
190/104 mmHg). Bilateral pupil was equal (diameter: 2 mm) and
Editor: N/A.
non-reflective to light. Mechanical ventilation was given immedi-
The patient has provided informed consent for publication of the case.
ately after admission. The head Computed Tomography (CT) scan
The study was approved by the ethics committee of Liaocheng People’s showed a large hematoma (about 11 ml) mainly located on the
Hospital.
dorsal side of pons extending to fourth ventricle and slightly
The authors have no funding and conflicts of interest to disclose.
enlarged lateral ventricles (Fig. 1A). With the family’s consent, we
Department of Neurosurgery, Liaocheng People’s Hospital, Liaocheng, China. performed hematoma evacuation together with posterior fossa
∗
Correspondence: Jianxin Zhu, Department of Neurosurgery, Liaocheng People’s decompression through a suboccipital midline approach for the
Hospital, Liaocheng 252000, China, (e-mail: [email protected]).
patient 3 hours after the onset. A small pathological artery was
Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc. coagulated gently with low bipolar cautery and no cerebrovascular
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
malformations were observed during the surgery. On the third day
reproduction in any medium, provided the original work is properly cited. after surgery, the patient regained the stable spontaneous breathing
How to cite this article: Hao G, Xu Z, Zhu J. Surgical treatment of spontaneous function and CT was performed showing that the hematoma was
brainstem hemorrhage: a case report. Medicine 2019;98:51(e18430). mostly removed (Fig. 1B). The patient was transferred to the
Received: 27 June 2019 / Received in final form: 29 October 2019 / Accepted: rehabilitation ward 2 weeks later. And he needed help for daily
14 November 2019 activities with hemiplegia of right limb at three-month follow-up
http://dx.doi.org/10.1097/MD.0000000000018430 (Glasgow Outcome Scale: 3).

1
Hao et al. Medicine (2019) 98:51 Medicine

Figure 1. Preoperative CT scan showed a large hematoma mainly located on pontine extending to fourth ventricle (A); Postoperative CT showed mostly removal of
the hematoma (B).

3. Discussion patient had a short onset, and the regular hematoma was located
Spontaneous brainstem hemorrhage is a rapid, devastating stroke, on the dorsal side extending to fourth ventricle. The normal tissues
with a high mortality up to 40% to 50%.[1,2] At the onset, rapid of the brainstem were not severely damaged, however, the
accumulation of hematoma on brainstem leads to disruption of compression of the hematoma was the major risk factor.
normal anatomy causing irreversible damage. However, the mass Fortunately, the patient regained normal spontaneous breathing
effect of the hematoma and the secondary damage of the blood cell function after surgery, and the patient’s left limbs could perform
degradation products can be alleviated by surgery. Moreover, some certain voluntary activities at 3-month follow-up. We hope
hematoma on brainstem degrades very slowly due to its lack of glial that the hematoma evacuation together with posterior fossa
cells. Fortunately, some case reports have provided evidence of the decompression in the super early stage maybe a good treatment for
effectiveness of microneurosurgery treatment for patients with patients in a deep coma with a large hematoma at the dorsal side.
primary brainstem hemorrhage, for it not only reduces mortality The small sample size is a limit of this study, and more further
but also improves functional outcome.[4,6,8] However, the data research should be done to develop a reasonable surgical guideline
about the surgery treatment enrolled in previous studies is really for treatment of spontaneous brainstem hemorrhage.
little and there is no special guideline applied to it from American
Heart Association/American Stroke. Author contributions
To provide optimal treatment, neurologists should first evaluate
Resources: Guangshan Hao, Zhentao Xu, Jianxin Zhu.
patients quickly and accurately. In recent studies, it has been
Writing – original draft: Guangshan Hao.
reported that the prognosis is highly dependent on the severity of
Writing – review & editing: Zhentao Xu, Jianxin Zhu.
clinical manifestations and some imaging indicators.[8] The
classification of brainstem hemorrhage based on CT performance
proposed by Chung and Park in 1992 has been widely accepted, in References
which the hemorrhages were roughly divided into 4 types: small [1] Murata Y, Yamaguchi S, Kajikawa H, et al. Relationship between the clinical
unilateral tegmental, basal tegmental, bilateral tegmental and manifestations, computed tomographic findings and the outcome in 80
massive.[9] Survival rate is the highest in small unilateral tegmental patients with primary pontine hemorrhage. J Neurol Sci 1999;167:107–11.
[2] Wijdicks EFM, StLouis E. Clinical profiles predictive of outcome in
type and lowest in massive type. According to the study of predictors pontine hemorrhage. Neurology 1997;49:1342–6.
mentioned above and some case reports of microneurosurgery [3] Sandalcioglu IE, Wiedemayer H, Secer S, et al. Surgical removal of brain
treatment together with our experiences, the current recommended stem cavernous malformations: surgical indications, technical consider-
surgical indications mainly based on the degree of coma and ations, and results. J Neurol Neurosurg Psychiatry 2002;72:351–5.
[4] Zhang HT, Chen LH, Bai MC, et al. Anterior subtemporal approach for
imaging result are as follows[4,6,8]: 1) GCS  8; 2) volume≥ 5 ml severe upper pontine hematomas: a report of 28 surgically treated cases. J
(concentrated and superficial). However, when the hematoma Clin Neurosci 2018;54:20–4.
volume is over 10 ml, patients may get a poor outcome no matter [5] Kim JY, Bae HJ. Spontaneous intracerebral hemorrhage: management. J
treated conservatively or surgically.[4] Time is also a very important Stroke 2017;19:28–39.
factor. Evacuation of the hematoma as soon as possible can not only [6] Shrestha BK, Ma L, Lan ZG, et al. Surgical management of spontaneous
hypertensive brainstem hemorrhage. Interdiscip Neurosur 2015;2:145–8.
relieve the compression effect but also avoid a series of secondary [7] Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the
damage. Some other reports also suggested a better prognosis of management of spontaneous intracerebral hemorrhage a guideline for
patients underwent surgery within 6 hours after the onset.[6] healthcare professionals from the American Heart Association/American
In this case, the massive hematoma caused respiratory failure. Stroke Association. Stroke 2015;46:2032–60.
[8] Tao CY, Li H, Wang JJ, et al. Predictors of surgical results in patients with
If the treatment was conservative treatment or palliative primary pontine hemorrhage. Turk Neurosurg 2016;26:77–83.
extraventricular drainage, then the patient may eventually have [9] Chung CS, Park CH. Primary pontine hemorrhage - a New Ct-
died due to prolonged compression on the brainstem. However, the Classification. Neurology 1992;42:830–4.