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Pontine Infact

Learning objectives

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  • Understand
  • Integrate
  • Reflect

Note that anatomical pictures of the pons are upside down compared with the CT/MRI except below

  • Usually lacunar type infarcts
  • Age, hypertension, diabetes, atherosclerosis
  • Pontine strokes are usually unilateral and reflect small vessel occlusion of penetrating vessels.
  • Occasionally a basilar artery occlusion blocking the ostia can result in bilateral infarction
  • Small vessel strokes share same risk factors as small vessel disease elsewhere with hypertension, diabetes and age as significant risk factors.
  • Large vessel basilar infarcts also share the same risk as other large vessel strokes including localised atherosclerosis and embolism.
  • The fact that the fourth ventricle lies behind the pons means that any swelling here can result in obstructive hydrocephalus which may require shunting.
  • Contralateral weakness and sensory symptoms
  • No cortical signs or hemianopia
  • Ipsilateral Facial palsy
  • Diplopia, Lateral gaze palsy if VIth nerve affected
  • Comatose, locked in syndrome with preservation of upward gaze, Pinpoint pupils
  • Pyrexias and autonomic dysfunction
  • LMN or UMN VIIth which is ipsilateral.
  • Variants of Quadriparesis due to corticospinal involvement
  • There may be waxing and waning of symptoms initially like a capsular warning syndrome
  • Sensory symptoms
  • Dysarthria - Clumsy hand type Lacunar syndromes
  • Vertigo, Dizziness due to involvement of cerebellar peduncles

Infarcts almost always respect the midline and can extend to cerebellum

  • FBC, U&E, LFTs, Glucose, lipids
  • CT/CTA as needed
  • MRI may show the infarct
  • Consider MRA to look for vascular stenosis
  • Reperfusion therapies where indicated - reperfusion of an MCA may increase flow to the lenticulostriate artery.
  • Admission to stroke unit
  • Aspirin 300 mg +/- Clopidogrel
  • Optimise BP control if hypertension and glucose control if diabetic
  • Statin to lower Cholesterol