Juvenile Primary Pontine Hemorrhage

A 12-year-old boy was admitted in a comatose state following a sudden episode of headache and vomiting. General physical examination and vital signs at admission were normal. A difference was noted in pupil sizes, the right being slightly larger, and light reactions of both pupils were sluggish. Bilateral deep tendon reflexes were exaggerated and decerebrate posturing was elicited by noxious stimuli. There was right hemiparesis, but facial palsy was not be observed. A lumbar tap revealed an opening pressure of 230 mm H2O and the fluid was bloody. Ventricular drainage was performed the following day. Conray ventriculography showed a filling defect in the posterior end of the third ventricle, but the aqueduct of Sylvius and the fourth ventricle were not visualized. Computed tomography (CT) revealed the presence of a high density lesion in the area between the left paramedian pontine tegmentum and the fourth ventricle. It was diagnosed as a primary pontine hemorrhage, and a ventriculo-peritoneal shunt was performed. Left vertebral angiography failed to show any abnormal findings such as vascular malformation. Ten days after admission, anisocoria disappeared. The patient's consciousness became clear one month after the onset. With improvement of the level of consciousness, the following abnormal neurological findings were noted. Ocular movement indicated the presence of the one-and-a-half syndrome, i.e., complete loss of horizontal movement of both eyes except for lateral gaze of the right eye accompanied by nystagmus. There were left peripheral facial palsy and right hemiparesis with exaggerated deep tendon reflexes plus a right Babinski response. Right hemiparesis improved after about one year. A CT scan performed two years after the onset revealed a non-enhanced low density area in the pontine tegmentum where the hematoma had been located. At present, the patient is in good health and attending junior high school.