====== Pontine hemorrhage (PH) ======
{{ ::pontinehemorrhagect.jpg?300|}}
Pontine [[hemorrhage]], is a [[intracranial hemorrhage]] in the [[pons]].

====Epidemiology===
Primary pontine hemorrhage (PPH) is rare, accounting for 5%-10% of [[intracranial hemorrhage]]s 
((Wessels T, Moller-Hartmann W, Noth J, Klotzsch C. CT findings and clinical features as markers for patient outcome in primary pontine hemorrhage. AJNR Am J Neuroradiol 2004;25:257-60.))

====Etiology====
Most commonly due to long standing poorly controlled chronic hypertension. 

see [[Pontine cavernous malformation]]
====Symptoms====
The clinical symptoms of PPH include not only sensorimotor dysfunction but also dysphagia, oculomotor ab- normality (dilated pupil), and respiration failure, which often lead to serious complications
((Murata Y, Yamaguchi S, Kajikawa H, Yamamura K, Su- mioka S, Nakamura S. Relationship between the clini- cal manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. J Neurol Sci 1999;167:107-11.)).

====Score====
Meguro et al proposed a Score
((Meguro T, Kuwahara K, Tomita Y, Okuma Y, Tanabe T, Muraoka K, Terada K,
Hirotsune N, Nishino S. Primary Pontine Hemorrhage in the Acute Stage: Clinical
Features and a Proposed New Simple Scoring System. J Stroke Cerebrovasc Dis. 2015
Feb 24. pii: S1052-3057(14)00601-6. doi:
10.1016/j.jstrokecerebrovasdis.2014.12.006. [Epub ahead of print] PubMed PMID:
25724243.))

were a GCS score of 6 or less, absence of pupillary light reflex, and plasma glucose of 10 mmol/L or greater are independent mortality predictors of PPH. The PPH score is a simple and reliable clinical grading scale for predicting 30-day mortality.
====Approaches====
Midline suboccipital

Retrosigmoid approach

Lateral transpeduncular approach

Far-lateral transcondylar approach

Supracerebellar infratentorial approach

Transsylvian-transpeduncular approach
====Outcome====
The mortality rate is high, ranging from approximately 40%-70% 
((Wijdicks EF, St Louis E. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology 1997;49: 1342-6.))
((Murata Y, Yamaguchi S, Kajikawa H, Yamamura K, Su- mioka S, Nakamura S. Relationship between the clini- cal manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. J Neurol Sci 1999;167:107-11.))
((Jung DS, Jeon BC, Park YS, Oh HS, Chun TS, Kim NK. The predictors of survival and functional outcome in patients with pontine hemorrhage. J Korean Neuro- surg Soc 2007;41:82-7.))
((Jang JH, Song YG, Kim YZ. Predictors of 30-day mor- tality and 90-day functional recovery after primary pontine hemorrhage. J Korean Med Sci 2011;26:100-7.)).

Multivariate analysis showed that Glasgow Coma Scale score <9, hyperthermia (a core temperature of ≥39°C), maximum hematoma diameter more than 27 mm, and hematoma extension to midbrain and/or thalamus were significantly related to PH-related death
((Matsukawa H, Shinoda M, Fujii M, Takahashi O, Murakata A. Risk factors for
mortality in patients with non-traumatic pontine hemorrhage. Acta Neurol Scand.
2014 Oct 2. doi: 10.1111/ane.12312. [Epub ahead of print] PubMed PMID: 25273885.)).
====Functional recovery====
Regarding functional recovery, the clinical parameters for a good outcome are considered to be an intact consciousness, good muscle power, and a normal pupil response
((Wijdicks EF, St Louis E. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology 1997;49: 1342-6.))
((Jang JH, Song YG, Kim YZ. Predictors of 30-day mor- tality and 90-day functional recovery after primary pontine hemorrhage. J Korean Med Sci 2011;26:100-7.)).

Only a few studies have been analyzed using different parameters, such as the Glasgow Outcome Scale, activity of daily living, and [[modified Rankin Scale]] (mRS). In these studies, good recovery rates were considered to be 40.7%-63% using the [[Glasgow Outcome Scale]]
((Wessels T, Moller-Hartmann W, Noth J, Klotzsch C. CT findings and clinical features as markers for patient outcome in primary pontine hemorrhage. AJNR Am J Neuroradiol 2004;25:257-60.))
((Wijdicks EF, St Louis E. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology 1997;49: 1342-6.))
((Murata Y, Yamaguchi S, Kajikawa H, Yamamura K, Su- mioka S, Nakamura S. Relationship between the clini- cal manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. J Neurol Sci 1999;167:107-11.))
and 54.5% using activity of daily living 
((Jung DS, Jeon BC, Park YS, Oh HS, Chun TS, Kim NK. The predictors of survival and functional outcome in patients with pontine hemorrhage. J Korean Neuro- surg Soc 2007;41:82-7.)).

Until now, clinical characteristics or radiological parameters, such as [[hematoma volume]] or transverse diameter measured using computerized tomography (CT), have been used to determine a predictive index of functional recovery in patients with PPH 
((Wessels T, Moller-Hartmann W, Noth J, Klotzsch C. CT findings and clinical features as markers for patient outcome in primary pontine hemorrhage. AJNR Am J Neuroradiol 2004;25:257-60.))
((Wijdicks EF, St Louis E. Clinical profiles predictive of outcome in pontine hemorrhage. Neurology 1997;49: 1342-6.))
((Murata Y, Yamaguchi S, Kajikawa H, Yamamura K, Su- mioka S, Nakamura S. Relationship between the clini- cal manifestations, computed tomographic findings and the outcome in 80 patients with primary pontine hemorrhage. J Neurol Sci 1999;167:107-11.))
((Jung DS, Jeon BC, Park YS, Oh HS, Chun TS, Kim NK. The predictors of survival and functional outcome in patients with pontine hemorrhage. J Korean Neuro- surg Soc 2007;41:82-7.))
((Jang JH, Song YG, Kim YZ. Predictors of 30-day mor- tality and 90-day functional recovery after primary pontine hemorrhage. J Korean Med Sci 2011;26:100-7.))
((Masiyama S, Niizuma H, Suzuki J. Pontine haemor- rhage: a clinical analysis of 26 cases. J Neurol Neuro- surg Psychiatry 1985;48:658-62.)).

The combined [[motor evoked potential]]s (MEP) and somatosensory evoked potential (SEP), is a reliable and useful tool for functional recovery after primary PH
((Seong JW, Kim MH, Shin HK, Lee HD, Park JB, Yang DS. Usefulness of the combined motor evoked and somatosensory evoked potentials for the predictive index of functional recovery after primary pontine hemorrhage. Ann Rehabil Med. 2014 Feb;38(1):13-8. doi: 10.5535/arm.2014.38.1.13. Epub 2014 Feb 25. PubMed
PMID: 24639921.)).

In 2010, Lee et al. 
((Lee SY, Lim JY, Kang EK, Han MK, Bae HJ, Paik NJ. Prediction of good functional recovery after stroke based on combined motor and somatosensory evoked potential findings. J Rehabil Med 2010;42:16-20.))
reported for the first time that the assessment of the combined MEP and SEP after stroke provides a better prediction of functional recovery than do MEP or SEP alone, and also confirmes that EP sum for mRS and functional ambulation category (FAC) has higher explanatory power than do MEP or SEP alone.

===Cognitive dysfunction===
Cognitive dysfunction is not rare after pontine hemorrhage. Therefore, for patients with infratentorial lesions, it is necessary to perform detailed cognitive functional tests
((Neki H, Yamane F, Osawa A, Maeshima S, Ishihara S. [Cognitive dysfunction in patients with pontine hemorrhage]. No Shinkei Geka. 2014 Feb;42(2):109-13.Japanese. PubMed PMID: 24501183.)).

The combined MEP and SEP is a reliable and useful tool for functional recovery after PPH.

===== Case reports =====

A 34-year-old woman presented with a history of persisting headache for years, and a newly developed dizziness, left facial palsy and right hemiparesis two days prior to this admission. Initial computed tomographic angiography of the head demonstrated an area of increased density in the left middle and posterior fossae. Multiple aneurysmally dilated venous ectasias with contrast enhancement at the left pre-pontine cistern causing a massive mass effect to the brainstem were also noted, suggesting a huge vascular abnormality. Digital subtraction angiography revealed an abnormal vascular lesion surrounding the brainstem, which indicated a left direct carotid-cavernous fistula with posterior drainage. As her consciousness deteriorated the next day, a follow-up computed tomography scan was done which revealed a pontine hemorrhage. Subsequently, endovascular closure of the fistula with sacrifice of the left ICA was performed, which successfully eliminated the imaging abnormalities
((Chan FH, Shen CY, Liu JT, Li CS. Brainstem hemorrhage caused by direct
carotid-cavernous fistula. A case report and literature review. Interv
Neuroradiol. 2014 Jul-Aug;20(4):487-94. doi: 10.15274/NRJ-2014-10038. Epub 2014
Aug 28. Review. PubMed PMID: 25207913; PubMed Central PMCID: PMC4187446.
)).