Isolated Medullary Hemorrhage: Clinical Features in Eleven Consecutive Patients

permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Most brainstem hemorrhages occurring in the pons and mid-brain, and hemorrhages restricted to the medulla oblongata have received little attention to date. Herein, we describe the clinical characteristics and prognosis of 11 patients (four men, age range of 11 patients: 20–65 years, mean age = 44) with medullary hemorrhage recruited consecutively from Seoul National University Bundang Hospital from July 2004–January 2016 (Figure 1). The most frequent symptoms in these patients included vertigo (n= 10), headache (n= 6), diplopia (n= 3), and limb weakness (n= 1). Table 1 shows the clinical features and prognosis of patients. More than half of patients (6/11, 55%) experienced minor transient or persistent neurologic symptoms, including vertigo (n= 3), sensory changes in the face (n= 2) or extremities (n= 2), dysarthria (n = 1), tinnitus (n = 1), and dysphagia (n = 1), within one month of presentation. In contrast, five patients (5/11, 46%) required advanced airway management in the intensive care unit. Hematoma expansion was observed in four patients during follow-up imaging (4/9, 44%). Patients usually had minor functional deficits three months after presentation (modified Rankin Scale ≤ 2 and/or Bathel Index 90; n= 8). All patients showed spontaneous nystagmus without fixation (n= 11; upbeat in eight, downbeat in one, and horizontal in two), which accompanied other neuro-otological findings (Table 2), including central positional nystagmus (7/9, 78%), gaze-evoked nystagmus (6/11, 55%), ocular lateropulsion (4/11, 36%), skew deviation (5/11, 45%), or abnormal head-impulse tests (3/11, 27%). The etiologies of the medullary hemorrhages were mostly cavernous malformation (n= 9), hemorrhagic transformation following lateral medullary infarction (n= 1, patient 5), or undeter-mined (n= 1, patient 1). In our patients, the presenting symptoms were mostly vertigo and headache. Furthermore, over half of the patients experienced prior minor neurologic symptoms, which is uncommon in pontine or midbrain hemorrhage. In contrast, most patients with pontine hemorrhage present with mental changes (47%) or hemiparesis (41%). 2 Likewise, patients with midbrain hemorrhage frequently show mental changes (53%), and limb weakness (49%). 3 Thus, we assume that the characteristics of hemorrhage secondary to cavernous malformation are different from those due to hypertensive hemorrhages. Intermingled vascular spaces or sinusoids would be affected less by arterial pressure than regions irrigated by small arterioles, which are vulnerable to hypertension. 4 Neurological impairments may worsen due to repeated seepage or oozing, …