A 50-year-old man experiences a sudden grand mal seizure. On examination he has papilledema on funduscopic examination of the right eye. MR imaging of his brain shows a large irregular mass with surrounding edema in the posterior frontal lobe. Which of the following forms of intracranial hemorrhage is most likely to complicate this man’s clinical course?
A. basal ganglia hemorrhage
B. pontine duret hemorrhage
C. epidural hematoma
D. subarachnoid hemorrhage
E. subdural hematoma
If I had to take a guess I'd say B. Pontine duret hemorrhage. The papilledema is a symptom of increased intracranial pressure and B is the only hemorrhage that is caused directly by increased ICP
Every cranial hemorrhage has a classic scenario associated with it. For example:
A. Basal ganglia hemorrhage is usually due to high blood pressure leading to Charcot-Bouchard aneurysms
B. The pontine hemorrhage is usually due to displacement of the brain stem downwards due to increased ICP. This displacement pushes the brain stem (and other parts of the brain) against bony structures which can cut off circulation or pinch nerve structures but it can also tear fragile blood vessels that supply the brain stem. That tearing will cause hemorrhage as well as cutting off circulation.
C. Epidural hematoma is usually a trauma-associated diagnosis especially over the temporal bone where the middle meningeal artery runs and the scenario will mention a lucid period following trauma with sudden loss of consciousness many hours after the incident
D. Subarachnoid hemorrhages are associated with aneurysms in the Circle of Willis and are usually described as sudden onset of the worst headache of the patient's life
E. Subdural hematoma is associated with the tearing of bridging veins which usually happens in 1) the elderly with atrophy of their cortex which pulls away from the meninges and stretches the bridging veins, making them susceptible and 2) children as a sign of being roughly shaken which is consistent with abuse.
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