Traumatic brain-stem hemorrhage

Abstract

PURPOSE : Traumatic brainstem hemorrhage is a very rare type of traumatic brain injury (TBI). According to the previous reports, frequent site of brainstem involvement is the midline rostral portion. The authors described four such cases of traumatic brainstem hemorrhage.

MATERIALS AND METHODS : #1. A 37-year-old man was admitted after pedestrian traffic accidents. Neurologic examination showed deep drowsy mentality, normal pupil reflex and intact motor function. Admission brain computed tomogram(CT) revealed intraparenchymal hemorrhage (IPH) on the right caudal portion of pons. After intensive medical care, follow-up CT showed resolving IPH, and patient was discharged without residual neurologic deficit. #2. A 44-tear-old man who suffered fall down from 3m height visited emergency room for evaluation of sustained headache. Initial neurologic examination did not revel any abnormal findings. However, pre-enhanced brain CT showed IPH at the pons, colliculus. On 9th hospital day, follow-up head CT revealed resolving hemorrhage. No neurological deficit was noticed.

RESULTS : #3. A 51-year-old man was referred to our institute following fall down from height. He was stuporous, fixed pupils (OD: 0.2 fixed, OS: 0.5 fixed) with right side motor deficit. Admission head CT scans revealed marked acute subdural hematoma(SDH), epidural hematoma(EDH), depressed skull fracture on left supratentorial region, and IPH on rostral portion of pons. Follow-up brain CT showed aggravation of hematoma and brain swelling. Urgent surgical intervention was performed for removal of fractured bone and hematoma. On 14th postoperative day, brain CT showed resolving hemorrhage. However, he remained stiporous. #4. A 56-year-old man with a 3m fall-down history was admitted with obtunded consciousness. Neurologic examination and head CT fialed to show any abnormal findings, except anisocoric pupil reflex. Brain MRI showed minimal hematoma on the rostral pons region. Despite conservative management with steroid, patients was discharged with anisocoric pupil size.

CONCLUSION : According to the present cases, the main type of injury was direct impact on the rostrocaudal axis and the rostral anterior brain stem was the most frequent location. In our cases, three cases without other brain lesion revealed a good recovery. Unless there is grave neurologic deficit following TBI, the possibility of brainstem hemorrhage is suspected, particularly if the mechanism of TBI was that of rostrocaudal impact such as fall-down.