the case.
A 34 year old male is bought to your ED with reduced level of consciousness. He was at a restaurant having dinner with family & friends when he excused himself to use the bathroom. They found him 15 minutes later slumped near the toilet – unconscious and barely breathing.
On arrival to ED, he is GCS 3 with pinpoint pupils. He has already received 2mg of naloxone by paramedics without affect.
Coma & Pin-Point Pupils.
- Neurological.
- Pontine stroke.
- Infarction
- Haemorrhage
- Pontine stroke.
- Toxicological.
- Opiates
- Clonidine
- Barbiturates
- Gamma-hydroxybutyrate [GHB]
- Cholinergics.
- organophosphates, carbamates
- nerve gas
- mushrooms
- Chloral hydrate
- Phenothiazines
- Atypical antipsychotics
- Olanzapine, quetiapine, clozapine
- Encephalopathy
Of course, some of these toxidromes will have associated features that will make them more or less likely given this limited clinical information.
After securing the airway, you transfer the patient to radiology for a non-contrast CT-brain….
Massive-type pontine haemorrhage.
Pontine Haemorrhage
Primary pontine haemorrhages are rare and account for only 5-10% of intracranial haemorrhages.
They are one of the classic locations for hypertensive intracerebral haemorrhages [along with the putamen, thalamus and cerebellum].
Other risk factors include;
- Vascular malformations [cavernous or arteriovenous]
- Anticoagulation
- Sympathomimetic abuse [esp. cocaine]
- Tumours [primary or metastatic]
- Smoking
Clinically;
- Severe disturbances of consciousness
- Abrupt and severe
- Stupor → coma !
- Oculomotor disturbances
- Pin-point pupils
- plus other cranial nerve findings
- Tetraparesis
- Respiratory failure
Management;
- Aggressive, upfront neuro-resuscitation.
- Secure airway [tape the tube, don’t tie]
- Adequate sedation post-intubation
- Avoid hypoxia & hypotension
- Avoid excessive PEEP
- Glucose control
- Neurosurgical.
- Open clot evacuation is typically avoided.
- Stereotactic haematoma aspiration may be offered.
Prognosis;
- Generally very poor & often fatal.
- Often fatal in the setting of hypertensive haemorrhage
- Predictors of poor outcome include:
- Coma on admission
- Intraventricular extension of haemorrhage
- Acute hydrocephalus
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- Murray L, Daly F, Little M & Cadogan M. Toxicology Handbook. 2nd Edition. Elsevier 2011
- Goto, N et al. Primary pontine hemorrhage: clinicopathological correlations. Stroke. 1980;11:84-90
- Shin, SC et al. Primary Pontine Hemorrhage. An Analysis of 35 Cases and Research in Prognostic Factors. Kor J Cerebrovascular Surgery. 2007: 9:41-5.
- Wessels T, et al. CT Findings and Clinical Features as Markers for Patient Outcome in Primary Pontine Hemorrhage. AJNR Am J Neuroradiol 25:257–260
- Nishizaki, T et al. Factors Determining the Outcome of Pontine Hemorrhage in the Absence of Surgical Intervention. Open Journal of Modern Neurosurgery, Vol. 2 No. 2, 2012, pp. 17-20
- Coma & small pupils – LITFL.com
- Pontine Haemorrhage at Radiopaedia.org
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