Page 77 - 14_Atti_SIN_SNO_2022_flip

Proceedings SNO “Percorsi clinici in Neuroscienze”

Case report IV SESSIONE
“LESIONI FOCALI INGANNEVOLI”

Hemorrhagic lesions of the brainstem:
cavernomas versus low grade gliomas

✧
G. BONOMO* , E. ZUCCHETTI**, P. FERROLI*
* Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milan, Italy
✧ University of Milan, Italy
** Department of Neurology, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milan, Italy

INTRODUCTION CASE REPORT

Up to 10% of intracerebral hemorrhages occur in the We present the case of a 16-year-old right-handed
brainstem. The highest mortality, up to 80%, is also male manifesting with sudden onset of pain in the
observed at this site. The risk of ICH increases with right eye, deviation of the labial rim to the left and
age and the prevalent cause of bleeding is hyperten- subsequent rapid deterioration of consciousness. He
(1,2)
sion in adults . In young people, however, second- was then admitted to intensive care unit and intubat-
ary causes often include vascular malformations, ed. CT and MRI of the brain revealed a bulbopontine
mainly aneurysms and arteriovenous malformations. brainstem haematoma without clarifying an underly-
Nevertheless, particularly in the young population, ing lesion (Figure 1). Cerebral angiography did not
brainstem tumors (medulloblastoma and gliomas) show any vascular malformations.
(3)
represent an increasingly frequent source for ICH . The patient exhibited a gradual recovery of con-
Frequently the hematoma masks the underlying le- sciousness and underwent tracheotomy and gastros-
sion of origin and it is not possible to adopt a target- tomy. On neurological examination, he displayed a
ed strategy to prevent further bleedings. Given the typical lateral medullary syndrome with contralateral
high risk of morbidity and mortality with each bleed, (left) in trunk and limbs and ipsilateral (right) facial
an invasive diagnostic approach through surgical thermodolorific sensation loss, dysphagia, dysphonia,
biopsy is indicated in these cases. nystagmus, vertigo, ipsilateral Horner’s syndrome
In this paper we present the case of a 16-year-old and ataxia. A typical facial colliculus syndrome was
male who presented recurrent brainstem bleedings also present with abduction deficit of the right eye
whose first diagnostic suspicion was cavernoma but with diplopia, right inferior facial paresis and hori-
whose bulbopontine biopsy revealed a rare entity, zontal conjugate gaze palsy.
FGFR1 mutated pilocytic astrocytoma. We expose The patient was moved to a rehabilitation setting with
the peculiar clinical picture by discussing aspects of slow and substantial improvement of symptoms.
radiological and histological differential diagnostics. An MRI of the brain at 3 months demonstrated the ef-
fects of the haematoma with a lesion compatible with

Corrispondenza: Dr. Giulio Bonomo, Dipartimento di Neurochirurgia, Istituto Neurologico C. Besta, via Celoria 11, 20133 Milan (MI),
e-mail: dott.giuliobonomo@gmail.com
Percorsi clinici in Neuroscienze. Clinical Round SIN e SNO Lombardia, 21 gennaio 2022, Desio (Monza e Brianza)
Atti a cura di Paolo Ferroli, Alessandra Protti, Andrea Salmaggi, Ignazio Michele Santilli, Luca Valvassori
Copyright © 2022 by new Magazine edizioni s.r.l., Trento, Italia. www.newmagazine.it ISBN: 978-88-8041-135-2

- 75 -