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Atheromatous stenosis of the basilar artery (BA) can cause pontine infarctions by superimposed thrombosis, which occlude the BA itself or the orifices of the branches of the BA. Pontine infarctions can occur following large thromboembolism lodging at the BA lumen. Emboli usually lodge in the distal portion of the BA, occluding the superior cerebellar artery (SCA) or orifices of branches of the distal BA. Lipohyalinosis and branch atheromatous disease of the penetrating small arteries are the major vascular pathologies in most patients who develop pontine infarction. Pontine infarctions are caused by a variety of vascular pathologies that can develop in large brain-supplying arteries. About 10% of all brain hemorrhages occur in the pons. Before the development of computed tomography (CT) scanning, primary pontine hemorrhages (PPH) were considered a uniformly fatal disease characterized by horizontal gaze paresis, pinpoint pupils, high fever, quadriparesis, and rapid onset of coma.
Little is known about long-term physical sequelae, cognitive functioning, and quality of life of children who have had a haemorrhagic stroke. Fifty-six patients (29 females, 27 males) under 16 years of age at time of the bleeding were studied. Mean age at time of bleeding was 7.7 years (range 1 month to 15.9 years). The primary site and cause of the bleeding at baseline were determined. Occurrences of death, re-bleedings, and seizures during follow-up were recorded. Patients who survived were invited for a follow-up examination including physical check-up, general screening of cognition, and an inventory of subjective health perception. Thirteen children died directly as a result of the haemorrhage; nine experienced a recurrent bleeding, which was fatal in three; six children developed epileptic seizures. At follow-up 36 of 56 patients were still alive. Mean follow-up time was 10.3 years (range 1.3 to 19.9 years) and mean age was 18.6 years (range 1.8 to 34.1 years). There was no patient lost to follow-up. Five patients declined to visit the hospital. In 15 out of 31 patients who could be examined, no physical impairment was observed, 11 had a hemiparesis of varying severity, and three had symptoms of cerebellar ataxia. One child had persisting tetraparesis and one persisting paraparesis. Signs of cognitive deficits were found in 15 patients. Of the children who survive haemorrhagic stroke, the physical and functional prognosis is relatively good, as almost all children were independent at follow-up. However, only a quarter of the surviving children had no physical or cognitive deficit after a mean follow-up period of 10 years. The majority had low self-esteem as well as emotional, behavioural, and health problems.
It is not the purpose of this chapter to go into great depth about the variety of disease conditions that may cause subarachnoid hemorrhage, but we should like to point out that 15% of spontaneous hemorrhages in the subarachnoid space are not caused by aneurysms (Table 49.1), and that certain elements of the history or the physical examination may sometimes point to one of these specific causes.
The key feature in diagnosing subarachnoid hemorrhage (SAH) is the history of sudden, severe and unusual headache. Classically it comes on in seconds (‘a flash’, ‘just like that’, ‘a bolt from a blue sky’, ‘as if I was hit on the head’), or in a few minutes at most. A potential pitfall is that patients may sometimes use the word ‘sudden’ to describe an episode of headache that came on in half an hour or longer, depending on the interval after which the history is given. And, even if the headache really comes on within seconds or minutes, such a history is not specific for ruptured aneurysms or even for SAH in general. Sudden onset headache may also occur with other intracranial hemorrhages, with non-hemorrhagic brain disease, and especially with innocuous forms of ‘thunderclap headache’: variants of vascular headache, migrainous or not, or of muscle contraction headache. Sexual activity may precipitate not only SAH, but also either type of the relatively harmless headaches (Lance, 1976; Pascual et al., 1996).
In general practice, exceptional forms of common headaches outnumber common forms of a rare disease, in this case a ruptured aneurysm.
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