Recommended Treatment for Patients with Massive Pontine Hemorrhage: Cases report and review
Main Article Content
Abstract
Primary pontine hemorrhage poses a significant treatment challenge due to the critical and compact anatomy of the brainstem. Massive PPH is typically associated with poor outcomes, and there is currently no consensus on treatment guidelines. We propose a clinical decisional framework based on radiologic and clinical criteria to identify patients who might benefit from active intervention. In this case series of 14 patients with massive ventral PPH, 5 patients died within the first week due to severe comorbidities. Of the 9 surviving patients, all underwent early tracheostomy and experienced minor complications. Among them, 2 patients with complete anterior pontine involvement on CT scans remained in a long-term vegetative state. The other 7 patients, who showed partial anterior sparing on imaging, demonstrated significant neurological improvement—following simple commands by week 4 and achieving partial functional recovery at 6 months. These patients were able to communicate effectively and regained varying degrees of mobility, although all remained dependent on assistance. Our findings support individualized decision-making and suggest that selected patients with massive PPH may benefit from full medical management.
Article Details
How to Cite
SRIPONTAN, Somkrit et al.
Recommended Treatment for Patients with Massive Pontine Hemorrhage: Cases report and review.
Medical Research Archives, [S.l.], v. 13, n. 9, sep. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6923>. Date accessed: 07 dec. 2025.
doi: https://doi.org/10.18103/mra.v13i9.6923.
Section
Case Reports
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Mangold SA, Das JM. Neuroanatomy, Reticular Formation. In: StatPearls. StatPearls Publishing; 2025. Accessed July 29, 2025. http://www.ncbi.nlm.nih.gov/books/NBK556102/
2. Milsom WK, Chatburn J, Zimmer MB. Pontine influences on respiratory control in ectothermic and heterothermic vertebrates. Respir Physiol Neurobiol. 2004;143(2-3):263-280. doi:10.1016/j.resp.2004.05.008
3. An SJ, Kim TJ, Yoon BW. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. J Stroke. 2017;19(1):3-10. doi:10.5853/jos.2016.00864
4. Ss W, Y Y, J V, et al. Management of brainstem haemorrhages. Swiss medical weekly. 2019;149. doi:10.4414/smw.2019.20062
5. Behrouz R. Prognostic factors in pontine haemorrhage: A systematic review. Eur Stroke J. 2018;3(2):101-109. doi:10.1177/2396987317752729
6. 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):257-260.
7. K B, T A, M K, Y C, U U. Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage. Clinical neurology and neurosurgery. 2005;108(1). doi:10.1016/j.cline uro.2005.02.007
8. Sripontan S. Good Outcome in a Patient with Massive Pontine Hemorrhage. Asian J Neurosurg. 2019;14(3):992-995. doi:10.4103/ajns.AJNS_295_18
9. Huang KB, Ji Z, Wu YM, Wang SN, Lin ZZ, Pan SY. The prediction of 30-day mortality in patients with primary pontine hemorrhage: a scoring system comparison. Eur J Neurol. 2012;19(9):1245-1250. doi:10.1111/j.1468-1331.2012.03724.x
10. Huang K, Ji Z, Sun L, et al. Development and Validation of a Grading Scale for Primary Pontine Hemorrhage. Stroke. 2017;48(1):63-69. doi:10.1161/S TROKEAHA.116.015326
11. Chung CS, Park CH. Primary pontine hemorrhage: a new CT classification. Neurology. 1992;42(4):830-834. doi:10.1212/wnl.42.4.830
12. 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):100-107. doi:10.3346/jkms.2011.26.1.100
13. Nishizaki T, Ikeda N, Nakano S, Sakakura T, Abiko M, Okamura T. Factors Determining the Outcome of Pontine Hemorrhage in the Absence of Surgical Intervention. Open Journal of Modern Neurosurgery. 2012;2(2):17-20. doi:10.4236/ojmn.2 012.22004
14. Murata Y, Yamaguchi S, Kajikawa H, 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): 107-111. doi:10.1016/s0022-510x(99)00150-1
15. Russell B, Rengachary SS, McGregor D. Primary pontine hematoma presenting as a cerebellopontine angle mass. Neurosurgery. 1986;19(1):129-133. doi:10.1227/00006123-198607000-00023
16. Ye Z, Huang X, Han Z, et al. Three-year prognosis of first-ever primary pontine hemorrhage in a hospital-based registry. J Clin Neurosci. 2015;22(7):1133-1138. doi:10.1016/j.jocn.2014.12.024
17. Knight J, Decker LC. Decerebrate and Decorticate Posturing. In: StatPearls. StatPearls Publishing; 2025. Accessed August 6, 2025. http://www.ncbi.nlm.nih.gov/books/NBK559135/
18. Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 2015;46(7): 2032-2060. doi:10.1161/STR.0000000000000069
19. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/ American Stroke Association. Stroke. 2022;53(7): e282-e361. doi:10.1161/STR.0000000000000407
20. Broderick JP, Adeoye O, Elm J. The Evolution of the Modified Rankin Scale and Its Use in Future Stroke Trials. Stroke. 2017;48(7):2007-2012. doi:10.1161/STROKEAHA.117.017866
21. S S, J I, W S. ปัจจัยที่มีผลต่อการพยากรณ์การรัก ษาในผู้ป่วยที่มีภาวะเลือดออกบริเวณก้านสมองระดับพอนส์ ในโรงพยาบาลมหาสารคาม. Journal of The Department of Medical Services. 2020;45(3):76-81.
22. Sridhar S, Khamaj A, Asthana MK. Cognitive neuroscience perspective on memory: overview and summary. Front Hum Neurosci. 2023;17:121 7093. doi:10.3389/fnhum.2023.1217093
23. Ackerman S. Major Structures and Functions of the Brain. In: Discovering the Brain. National Academies Press (US); 1992. Accessed August 31, 2025. https://www.ncbi.nlm.nih.gov/books/NBK234157/
24. Hong JH, Son SM, Jang SH. Somatotopic location of corticospinal tract at pons in human brain: a diffusion tensor tractography study. Neuroimage. 2010;51(3):952-955. doi:10.1016/j.neuroimage.20 10.02.063
25. Rahman M, Tadi P. Neuroanatomy, Pons. In: StatPearls. StatPearls Publishing; 2025. Accessed July 29, 2025.
http://www.ncbi.nlm.nih.gov/books/NBK560589/
26. Wang D. Reticular formation and spinal cord injury. Spinal Cord. 2009;47(3):204-212. doi:10.103 8/sc.2008.105
27. Jang SH, Chang CH, Jung YJ, Kwon HG. Hypersomnia due to injury of the ventral ascending reticular activating system following cerebellar herniation: A case report. Medicine (Baltimore). 2017; 96(1):e5678. doi:10.1097/MD.0000000000005678
28. Roob G, Schmidt R, Kapeller P, Lechner A, Hartung HP, Fazekas F. MRI evidence of past cerebral microbleeds in a healthy elderly population. Neurology. 1999;52(5):991-994. doi:10.1212/wnl.5 2.5.991
29. Kwa VI, Franke CL, Verbeeten B, Stam J. Silent intracerebral microhemorrhages in patients with ischemic stroke. Amsterdam Vascular Medicine Group. Ann Neurol. 1998;44(3):372-377. doi:10.1002/an a.410440313
30. Zafar A, Khan FS. Clinical and radiological features of intracerebral haemorrhage in hypertensive patients. J Pak Med Assoc. 2008;58(7):356-358.
31. Keep RF, Hua Y, Xi G. Intracerebral haemorrhage: mechanisms of injury and therapeutic targets. Lancet Neurol. 2012;11(8):720-731. doi:10.1016/S 1474-4422(12)70104-7
32. The Structural Factor of Hypertension | Circulation Research. Accessed August 7, 2025. https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.116.303596?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
33. Evans MRB, Weeks RA. Putting pontine anatomy into clinical practice: the 16 syndrome. Practical Neurology. 2016;16(6):484-487. doi:10.1136/pract neurol-2016-001367
34. Jeong JH, Yoon SJ, Kang SJ, Choi KG, Na DL. Hypertensive Pontine Microhemorrhage. Stroke. 2002;33(4):925-929. doi:10.1161/01.STR.0000013 563.73522.CB
35. Nakajima K. Clinicopathological study of pontine hemorrhage. Stroke. 1983;14(4):485-493. doi:10.1161/01.str.14.4.485
36. Nakajima K, Ito Z, Hen R, Suzuki A, Fukasawa H. [Clinicopathological study of pontile hemorrhage--II. Pathological aspects (author's transl]. No To Shinkei. 1977;29(11):1157-1165.
37. Dinsdale HB. SPONTANEOUS HEMORRHAGE IN THE POSTERIOR FOSSA.A STUDY OF PRIMARY CEREBELLAR AND PONTINE HEMORRHAGES WITH OBSERVATIONS ON THEIR PATHOGENESIS. Arch Neurol. 1964;10:200-217. doi:10.1001/archn eur.1964.00460140086011
38. Wilkinson DA, Pandey AS, Thompson BG, Keep RF, Hua Y, Xi G. Injury mechanisms in acute intracerebral hemorrhage. Neuropharmacology. 2018;134(Pt B): 240-248. doi:10.1016/j.neuropharm.2017.09.033
39. Song S, Hua Y, Keep RF, Hoff JT, Xi G. A New Hippocampal Model for Examining Intracerebral Hemorrhage-Related Neuronal Death. Stroke. 2007; 38(10):2861-2863. doi:10.1161/STROKEAHA.107.4 88015
40. Zhang Y, Khan S, Liu Y, et al. Modes of Brain Cell Death Following Intracerebral Hemorrhage. Front Cell Neurosci. 2022;16:799753. doi:10.3389/fncel.2 022.799753
41. Lekic T, Krafft PR, Coats JS, Obenaus A, Tang J, Zhang JH. Infratentorial Strokes for Posterior Circulation Folks: Clinical Correlations for Current Translational Therapeutics. Transl Stroke Res. 2011;
2(2):144-151. doi:10.1007/s12975-011-0068-2
42. Hata R, Matsumoto M, Hatakeyama T, et al. Differential vulnerability in the hindbrain neurons and local cerebral blood flow during bilateral vertebral occlusion in gerbils. Neuroscience. 1993;56(2):423-439. doi:10.1016/0306-4522(93)90343-e
2. Milsom WK, Chatburn J, Zimmer MB. Pontine influences on respiratory control in ectothermic and heterothermic vertebrates. Respir Physiol Neurobiol. 2004;143(2-3):263-280. doi:10.1016/j.resp.2004.05.008
3. An SJ, Kim TJ, Yoon BW. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. J Stroke. 2017;19(1):3-10. doi:10.5853/jos.2016.00864
4. Ss W, Y Y, J V, et al. Management of brainstem haemorrhages. Swiss medical weekly. 2019;149. doi:10.4414/smw.2019.20062
5. Behrouz R. Prognostic factors in pontine haemorrhage: A systematic review. Eur Stroke J. 2018;3(2):101-109. doi:10.1177/2396987317752729
6. 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):257-260.
7. K B, T A, M K, Y C, U U. Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage. Clinical neurology and neurosurgery. 2005;108(1). doi:10.1016/j.cline uro.2005.02.007
8. Sripontan S. Good Outcome in a Patient with Massive Pontine Hemorrhage. Asian J Neurosurg. 2019;14(3):992-995. doi:10.4103/ajns.AJNS_295_18
9. Huang KB, Ji Z, Wu YM, Wang SN, Lin ZZ, Pan SY. The prediction of 30-day mortality in patients with primary pontine hemorrhage: a scoring system comparison. Eur J Neurol. 2012;19(9):1245-1250. doi:10.1111/j.1468-1331.2012.03724.x
10. Huang K, Ji Z, Sun L, et al. Development and Validation of a Grading Scale for Primary Pontine Hemorrhage. Stroke. 2017;48(1):63-69. doi:10.1161/S TROKEAHA.116.015326
11. Chung CS, Park CH. Primary pontine hemorrhage: a new CT classification. Neurology. 1992;42(4):830-834. doi:10.1212/wnl.42.4.830
12. 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):100-107. doi:10.3346/jkms.2011.26.1.100
13. Nishizaki T, Ikeda N, Nakano S, Sakakura T, Abiko M, Okamura T. Factors Determining the Outcome of Pontine Hemorrhage in the Absence of Surgical Intervention. Open Journal of Modern Neurosurgery. 2012;2(2):17-20. doi:10.4236/ojmn.2 012.22004
14. Murata Y, Yamaguchi S, Kajikawa H, 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): 107-111. doi:10.1016/s0022-510x(99)00150-1
15. Russell B, Rengachary SS, McGregor D. Primary pontine hematoma presenting as a cerebellopontine angle mass. Neurosurgery. 1986;19(1):129-133. doi:10.1227/00006123-198607000-00023
16. Ye Z, Huang X, Han Z, et al. Three-year prognosis of first-ever primary pontine hemorrhage in a hospital-based registry. J Clin Neurosci. 2015;22(7):1133-1138. doi:10.1016/j.jocn.2014.12.024
17. Knight J, Decker LC. Decerebrate and Decorticate Posturing. In: StatPearls. StatPearls Publishing; 2025. Accessed August 6, 2025. http://www.ncbi.nlm.nih.gov/books/NBK559135/
18. Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 2015;46(7): 2032-2060. doi:10.1161/STR.0000000000000069
19. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/ American Stroke Association. Stroke. 2022;53(7): e282-e361. doi:10.1161/STR.0000000000000407
20. Broderick JP, Adeoye O, Elm J. The Evolution of the Modified Rankin Scale and Its Use in Future Stroke Trials. Stroke. 2017;48(7):2007-2012. doi:10.1161/STROKEAHA.117.017866
21. S S, J I, W S. ปัจจัยที่มีผลต่อการพยากรณ์การรัก ษาในผู้ป่วยที่มีภาวะเลือดออกบริเวณก้านสมองระดับพอนส์ ในโรงพยาบาลมหาสารคาม. Journal of The Department of Medical Services. 2020;45(3):76-81.
22. Sridhar S, Khamaj A, Asthana MK. Cognitive neuroscience perspective on memory: overview and summary. Front Hum Neurosci. 2023;17:121 7093. doi:10.3389/fnhum.2023.1217093
23. Ackerman S. Major Structures and Functions of the Brain. In: Discovering the Brain. National Academies Press (US); 1992. Accessed August 31, 2025. https://www.ncbi.nlm.nih.gov/books/NBK234157/
24. Hong JH, Son SM, Jang SH. Somatotopic location of corticospinal tract at pons in human brain: a diffusion tensor tractography study. Neuroimage. 2010;51(3):952-955. doi:10.1016/j.neuroimage.20 10.02.063
25. Rahman M, Tadi P. Neuroanatomy, Pons. In: StatPearls. StatPearls Publishing; 2025. Accessed July 29, 2025.
http://www.ncbi.nlm.nih.gov/books/NBK560589/
26. Wang D. Reticular formation and spinal cord injury. Spinal Cord. 2009;47(3):204-212. doi:10.103 8/sc.2008.105
27. Jang SH, Chang CH, Jung YJ, Kwon HG. Hypersomnia due to injury of the ventral ascending reticular activating system following cerebellar herniation: A case report. Medicine (Baltimore). 2017; 96(1):e5678. doi:10.1097/MD.0000000000005678
28. Roob G, Schmidt R, Kapeller P, Lechner A, Hartung HP, Fazekas F. MRI evidence of past cerebral microbleeds in a healthy elderly population. Neurology. 1999;52(5):991-994. doi:10.1212/wnl.5 2.5.991
29. Kwa VI, Franke CL, Verbeeten B, Stam J. Silent intracerebral microhemorrhages in patients with ischemic stroke. Amsterdam Vascular Medicine Group. Ann Neurol. 1998;44(3):372-377. doi:10.1002/an a.410440313
30. Zafar A, Khan FS. Clinical and radiological features of intracerebral haemorrhage in hypertensive patients. J Pak Med Assoc. 2008;58(7):356-358.
31. Keep RF, Hua Y, Xi G. Intracerebral haemorrhage: mechanisms of injury and therapeutic targets. Lancet Neurol. 2012;11(8):720-731. doi:10.1016/S 1474-4422(12)70104-7
32. The Structural Factor of Hypertension | Circulation Research. Accessed August 7, 2025. https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.116.303596?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
33. Evans MRB, Weeks RA. Putting pontine anatomy into clinical practice: the 16 syndrome. Practical Neurology. 2016;16(6):484-487. doi:10.1136/pract neurol-2016-001367
34. Jeong JH, Yoon SJ, Kang SJ, Choi KG, Na DL. Hypertensive Pontine Microhemorrhage. Stroke. 2002;33(4):925-929. doi:10.1161/01.STR.0000013 563.73522.CB
35. Nakajima K. Clinicopathological study of pontine hemorrhage. Stroke. 1983;14(4):485-493. doi:10.1161/01.str.14.4.485
36. Nakajima K, Ito Z, Hen R, Suzuki A, Fukasawa H. [Clinicopathological study of pontile hemorrhage--II. Pathological aspects (author's transl]. No To Shinkei. 1977;29(11):1157-1165.
37. Dinsdale HB. SPONTANEOUS HEMORRHAGE IN THE POSTERIOR FOSSA.A STUDY OF PRIMARY CEREBELLAR AND PONTINE HEMORRHAGES WITH OBSERVATIONS ON THEIR PATHOGENESIS. Arch Neurol. 1964;10:200-217. doi:10.1001/archn eur.1964.00460140086011
38. Wilkinson DA, Pandey AS, Thompson BG, Keep RF, Hua Y, Xi G. Injury mechanisms in acute intracerebral hemorrhage. Neuropharmacology. 2018;134(Pt B): 240-248. doi:10.1016/j.neuropharm.2017.09.033
39. Song S, Hua Y, Keep RF, Hoff JT, Xi G. A New Hippocampal Model for Examining Intracerebral Hemorrhage-Related Neuronal Death. Stroke. 2007; 38(10):2861-2863. doi:10.1161/STROKEAHA.107.4 88015
40. Zhang Y, Khan S, Liu Y, et al. Modes of Brain Cell Death Following Intracerebral Hemorrhage. Front Cell Neurosci. 2022;16:799753. doi:10.3389/fncel.2 022.799753
41. Lekic T, Krafft PR, Coats JS, Obenaus A, Tang J, Zhang JH. Infratentorial Strokes for Posterior Circulation Folks: Clinical Correlations for Current Translational Therapeutics. Transl Stroke Res. 2011;
2(2):144-151. doi:10.1007/s12975-011-0068-2
42. Hata R, Matsumoto M, Hatakeyama T, et al. Differential vulnerability in the hindbrain neurons and local cerebral blood flow during bilateral vertebral occlusion in gerbils. Neuroscience. 1993;56(2):423-439. doi:10.1016/0306-4522(93)90343-e