Recommended Treatment for Patients with Massive Pontine Hemorrhage: Cases report and review

Primary pontine hemorrhage poses a significant treatment challenge due to the critical and compact anatomy of the brainstem. Massive PPH is typically associated with poor outcomes, and there is currently no consensus on treatment guidelines. We propose a clinical decisional framework based on radiologic and clinical criteria to identify patients who might benefit from active intervention. In this case series of 14 patients with massive ventral PPH, 5 patients died within the first week due to severe comorbidities. Of the 9 surviving patients, all underwent early tracheostomy and experienced minor complications. Among them, 2 patients with complete anterior pontine involvement on CT scans remained in a long-term vegetative state. The other 7 patients, who showed partial anterior sparing on imaging, demonstrated significant neurological improvement—following simple commands by week 4 and achieving partial functional recovery at 6 months. These patients were able to communicate effectively and regained varying degrees of mobility, although all remained dependent on assistance. Our findings support individualized decision-making and suggest that selected patients with massive PPH may benefit from full medical management.