Arq Neuropsiquiatr 1998;56(1):129-132

PONTINE TEGMENTUM HEMATOMA
REPORT OF A CASE WITH PURE HEMIPLEGIA
ANTONIO CARLOS DE PÁDUA MILAGRES*, FLÁVIO ALÓE**,
JOÃO CARLOS PAPATERRA LIMONGI**

ABSTRACT- The authors report the case of a 50 year-old hypertensive male patient with a pontine hematoma.
The clinical presentation was characterized by pure pyramidal deficit signs (no other signs or symptoms were
present). A pure hemiplegia syndrome, although common in supratentorial lesions, is considered to be a rare
event in pontine vascular lesions. The pathophysiologic mechanisms of these neurological findings are unclear.
The exclusive involvement of the pyramidal tract in this case is likely due to a variation in the vascular anatomy
of the pons but, in some cases, a vascular malformation may be the cause.
KEY WORDS: pontine hemorrhage, pyramidal syndrome, pure hemiplegia.
Hematoma do tegmento pontino: relato de caso com hemiplegia pura
RESUMO- Os autores relatam o caso um paciente de sexo masculino de 50 anos de idade com hipertensão
arterial sistêmica que apresentava um hematoma pontino. A única manifestação clínica era caracterizada por
síndrome piramidal pura sem outros sinais ou sintomas neurológicos. A ausência de acometimento de outras
estruturas do tronco cerebral neste caso decorre possivelmente de variação da anatomia vascular do segmento
pontino do tronco cerebral e constitui evento pouco comum em hematomas dessa região.
PALAVRAS-CHAVE: hemorragia pontina, síndrome piramidal, hemiplegia pura.

Several clinical syndromes have been reported to exist in accordance to the extension and
specific sites of involvement of brainstem hematoma2-4,7,10,13,14,16,17,21,22. Different clinical manifestations
can result either from destruction of structures or from the compressive effects exerted by the hematoma
upon brainstem nuclei and fibers1,3. Elevated blood pressure has been emphasized repeatedly as an
etiologic factor in the development of pontine hemorrhage12. It is also possible that vascular malformations
could produce pontine hematoma and that the hemorrhage itself could obliterate the typical histologic
organization15. Teilmann, in his extensive review of the literature, referred to a few case reports in
which the apoplectic onset of a hemipontine syndrome was associated with survival for a prolonged
period of time, subsequent pathologic examination revealed findings consistent with vascular
malformation in some of his cases. This could be expected to occur in only a small minority of cases23.
Almost all primary pontine hemorrhages (PPH) occur in hypertensive persons, most of them
having no prior symptoms of cerebral vascular disease although in some series nearly 50% of patients
had a clinical history of previous hemiplegic strokes6,20. Among various types of intracerebral bleeding,
primary pontine hemorrhage is known to have the worst prognosis. Following a sudden onset, there

Department of Neurology, University of São Paulo Medical School General Hospital, São Paulo-SP,
Brazil: *Neurology resident,**Emergency ward attending neurologist. Aceite: 24-outubro-1997.
Dr. Antonio Carlos de Pádua Milagres - Rua Oscar Freire 1606 apto 11A - 05409-010 São Paulo SP - Brasil.
E mail albeflav@usp.br

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is often coma with tetraplegia, decerebrate posturing, respiratory disturbance, hyperthermia, and
pin-point pupils. Mortality rate due to pontine hemorrhage is reported to range from 30 to 68.7%12,16,23.
Tanaka et al22. classified pontine hemorrhage into [1]massive type, [2] tegmentum basis type, and[3]
tegmentum type. It was noted that the prognosis for long-term survival and functional recovery for
tegmentum type hemorrhage cases is good, the massive type being devastating. The prognosis for
basis tegmentum type hemorrhage stands between the other two.
The authors report on a case of pontine hemorrhage in which a pure motor hemiplegia (PMH)
was found as the only symptom. In 1965, a study published by Fisher and Curry7 outlined the
clinical criteria of PMH: complete or incomplete paralysis of the face, arm, and leg without loss of
sensation or disturbance of visual field, no dysphasia, apraxia or agnosia21. Although considered a
common finding in specific settings of hemispheric strokes, PMH is quite unusual as the clinical
manifestation of pontine hemorrhage.

CASE REPORT
A 50 year-old male was admitted to the emergency room because of sudden weakness on his right leg and
arm. An elevated arterial blood pressure (200/130 mmHg) was disclosed but his general physical exam was
otherwise unremarkable. Neurological examination revealed a complete right-sided hemiparesis. Consciousness
was not impaired and there were no cerebellar signs or cranial nerves dysfunction. There were no signs of
ipsilateral or contralateral VIIth nerve palsy but a supranuclear facial palsy was present. A mild dysarthria was
recorded and the patient referred no dizziness, tinnitus or dysphagia. Previous medical history indicated untreated
elevated blood pressure for the last 5 years. A computed tomographic (CT) scan showed a hematoma located in
the left pontine tegmentum (Fig 1).
He was discharged on the 7th in-hospital day with only a discrete dysarthria. No significant motor weakness
was recorded at discharge. The patient was submitted to a magnetic resonance imaging of the head three months
after discharge. Multiple hyper-signal images in T2 were recorded throughout the subcortical white matter as
well as in the pons. A left midpons negative signal was recorded which was indicative of hemosiderin or
calcification (Fig 2).

DISCUSSION
Brainstem hemorrhage has been extensively reported in the literature and focus
specifically on the different pontine lesions and
their clinical manifestations, etiologic factors,
treatment and prognosis 3,4,6,8,10. The clinical
presentation of a pontine hemorrhage varies
considerably and depends on the site of the
hematoma and its extension2,-4,10,14. Involvement
of cranial nerve function in association with
cerebellar and pyramidal tract dysfunction with
tetraplegia is the rule in the clinical presentation
of extensive bilateral pontine hematomas 2,4,9,10,12,14,17,18
. Other clinical manifestations are
coma, abnormal postures, punctiform pupils,
changes in blood pressure and abnormal
breathing patterns10.

Fig 1. CT scan showing a hematoma located in the left
pontine tegmentum.

The etiologic PPH factors more commonly reported in the literature are hypertensive hemorrhages and arteriovenous malformations13,19. It is
generally accepted that about 10% of all cerebral
hemorrhages occur in the pons10.

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Fig 2. MRI of head showing in T1 a negative signal which was indicative of hemosiderin or calcification. T2
showed a hyper-signal in the left midpons.

The lack of intraventricular bleeding and the favorable outcome on follow-up associated with
a diagnosis of hypertension led the authors to believe that an arteriovenous malformation was not
the underlying etiology in this case although an arteriogram would conclusively exclude this
possibility. Aleksic and Budzilovich2, Caplan and Goodwin4 and Gillilan8 discussed the anatomic
correlation between brainstem blood vessels and different diagnostic possibilities. According to
these authors, the distribution of the arterial branches in the pons, mainly under the intrinsic circulation
viewpoint, composes distinct topographic zones that in turn may generate distinct clinical syndromes.
The case reported herein displayed a head CT scan documenting hemorrhage located on the left
paramedian pontine tegmentum (Fig 1). Involvement of the median perforating branches of the
superficial arteries of the median line, that is, anterior spinal, vertebral and basilar arteries was
likely in this patient. The pyramidal tract is irrigated mainly by median and paramedian branches
along its course within the brain stem5,8. The clinical involvement of the pyramidal tract may be
produced either directly by an impairment of its arterial supply or indirectly by compression.
The importance of early CT in the diagnosis and management of such cases is clear. A patient
suffering from brainstem stroke may be considered a candidate for anticoagulant therapy. Such an
action would be clearly contraindicated if fresh hemorrhage is noted on CT scan. Our review indicate
that persons suffering hemorrhage into the pons who have preserved consciousness, particularly with unilateral
hematoma, have a more favorable prognosis. In these cases, vigorous supportive care is warranted.
Although PPH has been usually classified into three types as mentioned above, their clinical
significance is still uncertain, since their prognosis are not significantly different except for the small
unilateral tegmental type. Thus, for prognostic purposes, it may be best to classify PPH into the small
unilateral tegmental type and others (massive, basal-tegmental, and bilateral tegmental). The survival
rate was 94.1% for the small unilateral tegmental type as opposed to 18.2% for the others5.
A lateral tegmental brainstem hemorrhage syndrome has been recognized and it manifests
clinically with ipsilateral conjugated gaze palsy, ipsilateral internuclear ophthalmoplegia, a small
reactive pupil, ipsilateral ataxia and contralateral sensorimotor impairment3,11.

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A hemorrhagic origin of PMH is considered classically to be a rare event and was reported
only once in the literature9. Fisher and Curry did not find any case of hemorrhage in their series of
cases. However, they did not exclude the existence of hemorrhage as a cause of PMH 7.
The case reported herein had a lesion in the left pontine tegmentum without the other signs of
cerebellar, ocular movement, Vth and VIIth cranial nerve dysfunction. There were clear signs of
pyramidal tract involvement in the pons, a finding usually not reported in the literature as the only
clinical manifestation. The absence of neurological signs other than pyramidal tract can only be
explained by a variation in the vascular anatomy of the pons.

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