CT Case 088
A 42-year-old male has a collapse while at work.
He has a GCS of 3 on arrival of the paramedics and is intubated on scene.
On arrival to the emergency department he has a SBP 180 a temperature of 40°C (104°F).
His ECG is shown below

Urgent CT brain was performed
Describe and interpret the CT scans
There is an intraparenchymal brainstem haemorrhage involving the midbrain and pons with mild associated oedema and intraventricular extension into fourth ventricle.
As the paramedian perforators are the most common source of bleed, haemorrhage is often centrally located. These bleeds tend to extend along the long tracts in the brainstem stopping below the inferior midbrain cranially and the pontomedullary junction caudally.
Intraventricular haemorrhage extends into the lateral ventricles and fourth ventricle.
The lateral ventricles are mildly enlarged, indicating early hydrocephalus.
There is also an incidental finding of a lesion in the pineal gland.
Clinical Pearls
Primary brainstem haemorrhage (PBSH) is the most fatal subtype of ICH and is invariably associated with poor prognosis and a high mortality. The management is primarily conservative.
The four main surgical options are craniotomy, stereotactic haematology puncture and drainage, endoscopic haematoma removal and external ventricular drainage.
PBSH is usually related to chronic hypertension. Most frequently the haemorrhage occurs in the region of the pons constituting approximately 6-10% of ICH, other types are medullary and midbrain haemorrhage.
In all patients, and particularly in the absence of risk factors for a hypertensive bleed, an underlying lesion or vascular malformation needs to be ruled out, usually by MRI.
Central hyperthermia with a temperature >39°C (104°F).
, as in this case, is a common complication after PBSH and is usually unresponsive to conventional antipyretic measures.
This man was managed with an EVD and on day 7 became an organ donor.
Interestingly his ECG on ED arrival shows classic cerebral T waves.
References
- Asif KS et al. Endovascular Treatment in Acute Basilar Artery Occlusion Stroke: A Brief Practice Update From the Society of Vascular and Interventional Neurology. Stroke: Vascular and Interventional Neurology, 2024; 4: 2.
- Cadogan M. Cerebral T waves. LITFL
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Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.