Surgical management of hematomas of the brain stem

Restricted access

✓ Nine patients with brain-stem hematoma were admitted to the authors' institute during the period from 1985 to 1988. Clinical symptoms and signs pointed to pontine involvement in most cases. Progressive clinical deterioration was quite common and usually led to a clinical diagnosis of brain-stem intra-axial tumor. Angiography was noncontributory; computerized tomography (CT) was the main diagnostic test. This gave evidence of different pathological characteristics, including masses showing highly increased density, nonhomogeneous hyperdense lesions, and isodense lesions with peripheral contrast enhancement. No clear correlation was found, however, between the presumed duration of the clinical picture and the CT characteristics of the lesion. In the last four cases, magnetic resonance imaging was performed using a 0.015-tesla resistive system. This examination usually confirmed the presence of a brain-stem mass already shown by previous CT scans. There were, however, no cases in which direct evidence of an intra-axial vascular malformation could be obtained. The patients were all treated surgically with an attempt at total removal of the lesion and thorough inspection of the hematoma cavity and biopsy. Evidence of “cryptic” arteriovenous malformation was obtained in six of the nine cases. There were minor transitory complications in three cases. All of the patients were able to resume their previous activity, and none suffered recurrence of the symptoms following the operation. It may be concluded that surgery is the treatment of choice for brain-stem hematoma.

Article Information

Address reprint requests to: Aldo Spallone, M.D., 2nd University of Rome, “Tor Vergata” Via Orazio Raimondo, 00173 Rome, Italy.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 1. Computerized tomography scan shows an area of highly increased density located eccentrically into the brain stem. Note the deformed fourth ventricle.

  • View in gallery

    Left: Preoperative computerized tomography (CT) scan with contrast enhancement. An isodense round, regular-shaped mass is seen intrinsic to the brain stem, with a fine ring of contrast enhancement. The fourth ventricle is partly obliterated due to bulging of the floor. Right: Postoperative CT scan without contrast enhancement obtained 7 days following surgery. The brain stem and fourth ventricle have resumed their normal shape. There is a small area of increased density within the hematoma cavity, which likely represents Oxycel packing filled with old blood clots.

  • View in gallery

    Preoperative computerized tomography scan following administration of contrast medium showing a mass of nonhomogeneous increased density with high peripheral contrast enhancement. This mass involves the right half of the pons and obliterates the cerebellopontine angle cistern.

  • View in gallery

    Left: Intraoperative views under the operating microscope showing a discrete bulging of the floor of the fourth ventricle. Right: Following incision of the floor of the fourth ventricle, the hematoma was completely removed and abnormal vessels coagulated. The residual cavity is shown.

References

1.

Abe MKjellberg RNAdams RD: Clinical presentations of vascular malformations of the brain stem: comparison of angiographically positive and negative types. J Neurol Neurosurg Psychiatry 52:1671751989Abe M Kjellberg RN Adams RD: Clinical presentations of vascular malformations of the brain stem: comparison of angiographically positive and negative types. J Neurol Neurosurg Psychiatry 52:167–175 1989

2.

Arseni CStanciu M: Primary haematomas of the brain-stem. Acta Neurochir 28:3233301973Arseni C Stanciu M: Primary haematomas of the brain-stem. Acta Neurochir 28:323–330 1973

3.

Beatty RMZervas NT: Stereotactic aspiration of a brain stem hematoma. Neurosurgery 13:2042071983Beatty RM Zervas NT: Stereotactic aspiration of a brain stem hematoma. Neurosurgery 13:204–207 1983

4.

Becker DHSilverberg GD: Successful evacuation of an acute pontine hematoma. Surg Neurol 10:2632661978Becker DH Silverberg GD: Successful evacuation of an acute pontine hematoma. Surg Neurol 10:263–266 1978

5.

Bergstrom MEricson KLevander Bet al: Variation with time of the attenuation values of intracranial hematomas. J Comput Assist Tomogr 1:57631977Bergstrom M Ericson K Levander B et al: Variation with time of the attenuation values of intracranial hematomas. J Comput Assist Tomogr 1:57–63 1977

6.

Bosch DABeute GN: Successful stereotaxic evacuation of an acute pontomedullary hematoma. Case report. J Neurosurg 62:1531561985Bosch DA Beute GN: Successful stereotaxic evacuation of an acute pontomedullary hematoma. Case report. J Neurosurg 62:153–156 1985

7.

Dinsdale HB: Spontaneous hemorrhage in the posterior fossa. A study of primary cerebellar and pontine hemorrhage with observations on their pathogenesis. Arch Neurol 10:2002171964Dinsdale HB: Spontaneous hemorrhage in the posterior fossa. A study of primary cerebellar and pontine hemorrhage with observations on their pathogenesis. Arch Neurol 10:200–217 1964

8.

Doczí TThomas DGT: Successful removal of an intrapontine haematoma. J Neurol Neurosurg Psychiatry 42:105810611979Doczí T Thomas DGT: Successful removal of an intrapontine haematoma. J Neurol Neurosurg Psychiatry 42:1058–1061 1979

9.

Epstein FMcCleary EL: Intrinsic brain-stem tumors of childhood: surgical indications. J Neurosurg 64:11151986Epstein F McCleary EL: Intrinsic brain-stem tumors of childhood: surgical indications. J Neurosurg 64:11–15 1986

10.

Fasano VAUrciuoli RPonzio RMet al: The effects of new technologies on the surgical management of brain-stem tumors. Surg Neurol 25:2192261986Fasano VA Urciuoli R Ponzio RM et al: The effects of new technologies on the surgical management of brain-stem tumors. Surg Neurol 25:219–226 1986

11.

Goto NKaneko MHosaka Met al: Primary pontine hemorrhage: clinicopathological correlations. Stroke 11:84901980Goto N Kaneko M Hosaka M et al: Primary pontine hemorrhage: clinicopathological correlations. Stroke 11:84–90 1980

12.

Konovalov ANAtieh J: The surgical treatment of primary brain stem tumors in Schmidek HHSweet WH (eds): Operative Neurosurgical Techniques. Indications Methods and Resultsed 2. New York: Grune & Stratton1988 pp 709737Konovalov AN Atieh J: The surgical treatment of primary brain stem tumors in Schmidek HH Sweet WH (eds): Operative Neurosurgical Techniques. Indications Methods and Results ed 2. New York: Grune & Stratton 1988 pp 709–737

13.

Koos WTSunder-Plassmann MSalah S: Successful removal of a large intrapontine hematoma. Case report. J Neurosurg 31:6906941969Koos WT Sunder-Plassmann M Salah S: Successful removal of a large intrapontine hematoma. Case report. J Neurosurg 31:690–694 1969

14.

Lassiter KRLAlexander E JrDavis CH Jret al: Surgical treatment of brain stem gliomas. J Neurosurg 34:7197251971Lassiter KRL Alexander E Jr Davis CH Jr et al: Surgical treatment of brain stem gliomas. J Neurosurg 34:719–725 1971

15.

La Torre EDelitala ASorano V: Hematoma of the quadrigeminal plate. Case report. J Neurosurg 49:6106131978La Torre E Delitala A Sorano V: Hematoma of the quadrigeminal plate. Case report. J Neurosurg 49:610–613 1978

16.

Mangiardi JREpstein FJ: Brainstem haematomas: review of the literature and presentation of five new cases. J Neurol Neurosurg Psychiatry 51:9669761988Mangiardi JR Epstein FJ: Brainstem haematomas: review of the literature and presentation of five new cases. J Neurol Neurosurg Psychiatry 51:966–976 1988

17.

Mattos Pimenta LHMattos Pimenta AZuckerman E: Pontine haematoma: successful removal of two cases with review of 22 cases previously described in accessible literature. Neurosurg Rev 4:1391421981Mattos Pimenta LH Mattos Pimenta A Zuckerman E: Pontine haematoma: successful removal of two cases with review of 22 cases previously described in accessible literature. Neurosurg Rev 4:139–142 1981

18.

McCormick WFNofzinger JD: “Cryptic” vascular malformations of the central nervous system. J Neurosurg 24:8658751966McCormick WF Nofzinger JD: “Cryptic” vascular malformations of the central nervous system. J Neurosurg 24:865–875 1966

19.

Norman DPrice DBoyd Det al: Quantitative aspects of computed tomography of the blood and cerebrospinal fluid. Radiology 123:3353381977Norman D Price D Boyd D et al: Quantitative aspects of computed tomography of the blood and cerebrospinal fluid. Radiology 123:335–338 1977

20.

Obrador SDierssen GOdoriz BJ: Surgical evacuation of a pontine-medullary hematoma. Case report. J Neurosurg 33:82841970Obrador S Dierssen G Odoriz BJ: Surgical evacuation of a pontine-medullary hematoma. Case report. J Neurosurg 33:82–84 1970

21.

O'Laoire SACrockard HAThomas DGTet al: Brain-stem hematoma. A report of six surgically treated cases. J Neurosurg 56:2222271982O'Laoire SA Crockard HA Thomas DGT et al: Brain-stem hematoma. A report of six surgically treated cases. J Neurosurg 56:222–227 1982

22.

Ondra SLDoty JRMahla MEet al: Surgical excision of a cavernous hemangioma of the rostral brain stem: case report. Neurosurgery 23:4904931988Ondra SL Doty JR Mahla ME et al: Surgical excision of a cavernous hemangioma of the rostral brain stem: case report. Neurosurgery 23:490–493 1988

23.

Papo IPasquini USalvolini U: Subependymal brainstem hematomas: a report of two cases. Neuroradiology 11:2792821976Papo I Pasquini U Salvolini U: Subependymal brainstem hematomas: a report of two cases. Neuroradiology 11:279–282 1976

24.

Pouyanne MGot MJulien Jet al: Deux cas d'hématome intraprotubérantiels opérés. Étude critique. Soc Neurochir 13:7387421967Pouyanne M Got M Julien J et al: Deux cas d'hématome intraprotubérantiels opérés. Étude critique. Soc Neurochir 13:738–742 1967

25.

Scott BBSeeger JFSchneider RC: Successful evacuation of a pontine hematoma secondary to rupture of a pathologically diagnosed “cryptic” vascular malformation. Case report. J Neurosurg 39:1041081973Scott BB Seeger JF Schneider RC: Successful evacuation of a pontine hematoma secondary to rupture of a pathologically diagnosed “cryptic” vascular malformation. Case report. J Neurosurg 39:104–108 1973

26.

Stroink ARHoffman HJHendrick EBet al: Transependymal benign dorsally exophytic brain stem gliomas in childhood: diagnosis and treatment recommendations. Neurosurgery 20:4394441987Stroink AR Hoffman HJ Hendrick EB et al: Transependymal benign dorsally exophytic brain stem gliomas in childhood: diagnosis and treatment recommendations. Neurosurgery 20:439–444 1987

27.

Teilmann K: Hemangiomas of the pons. Arch Neurol Psychiatry 69:2082231953Teilmann K: Hemangiomas of the pons. Arch Neurol Psychiatry 69:208–223 1953

28.

Tsutsui TOhno MSymon Let al: Combined measurement of brain-stem auditory and somatosensory evoked potentials in a surgically treated brainstem hematoma. Surg Neurol 25:5755811986Tsutsui T Ohno M Symon L et al: Combined measurement of brain-stem auditory and somatosensory evoked potentials in a surgically treated brainstem hematoma. Surg Neurol 25:575–581 1986

29.

Vaquero JAreitio ELeunda Get al: Hematomas of the pons. Surg Neurol 14:1151181980Vaquero J Areitio E Leunda G et al: Hematomas of the pons. Surg Neurol 14:115–118 1980

30.

Zuccarello MIavicoli RPardatscher Ket al: Primary brain stem haematomas. Diagnosis and treatment. Acta Neurochir 54:45521980Zuccarello M Iavicoli R Pardatscher K et al: Primary brain stem haematomas. Diagnosis and treatment. Acta Neurochir 54:45–52 1980

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 12 12 6
Full Text Views 105 105 25
PDF Downloads 77 77 8
EPUB Downloads 0 0 0

PubMed

Google Scholar