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
- Pontine stroke.
- 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]
[DDET The case continues…]
After securing the airway, you transfer the patient to radiology for a non-contrast CT-brain….
[/DDET]
[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
Clinically;
- Severe disturbances of consciousness
- Abrupt and severe
- Stupor → coma !
- Oculomotor disturbances
- Pin-point pupils
- plus other cranial nerve findings
- Tetraparesis
- Respiratory failure
Management;
- 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.
Prognosis;
- 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
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[DDET References]
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- Murray L, Daly F, Little M & Cadogan M. Toxicology Handbook. 2nd Edition. Elsevier 2011
- Goto, N et al. Primary pontine hemorrhage: clinicopathological correlations. Stroke. 1980;11:84-90
- 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.
- 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
- 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
- Coma & small pupils – LITFL.com
- Pontine Haemorrhage at Radiopaedia.org
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