pupils predict pathology…

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.

[DDET What are your differential diagnoses in this case?]

Coma & Pin-Point Pupils.

  • Neurological.
    • Pontine stroke.
      • Infarction
      • Haemorrhage
  • 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.


[DDET The case continues…]

After securing the airway, you transfer the patient to radiology for a non-contrast CT-brain….

Massive-type pontine haemorrhage.
Massive-type pontine haemorrhage.


[DDET The diagnosis ?!?]

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


  • Severe disturbances of consciousness
    • Abrupt and severe
    • Stupor → coma !
  • Oculomotor disturbances
    • Pin-point pupils
    • plus other cranial nerve findings
  • Tetraparesis
  • Respiratory failure


  • 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.


  • 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


[DDET References]

  1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
  2. Murray L, Daly F, Little M & Cadogan M. Toxicology Handbook. 2nd Edition. Elsevier 2011
  3. Goto, N et al. Primary pontine hemorrhage: clinicopathological correlations. Stroke. 1980;11:84-90
  4. 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.
  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
  6. 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
  7. Coma & small pupils – LITFL.com
  8. Pontine Haemorrhage at Radiopaedia.org 


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