Primary medullary hemorrhage. Report of four cases and review of the literature.

Abstract

Primary medullary hemorrhage is uncommon. Its clinical profile and prognosis are not well known. We report four cases of medullary hemorrhage and a review of the English and French literature since 1964 to analyze the clinical presentation and prognosis. Of sixteen case reports of medullary hemorrhage reviewed from the literature, sixteen contained sufficient information for review and are included in this report. The age distribution of the patients was between 13 and 72 years, and 10 of these patients were men. The most frequent symptoms at onset were vertigo, sensory symptoms, and dysphagia. Presenting signs included palatal weakness, nystagmus, hypoglossal palsy, cerebellar ataxia, and limb weakness. The diagnosis was made at autopsy in 3 patients, at surgery in 3, by computed tomography in 4, and more recently by magnetic resonance imaging in 6. In nine instances the etiology of hemorrhage was undetermined; a ruptured vascular malformation was the cause in 3 patients, 1 was attributed to the use of anticoagulants, and hypertension was the suspected cause in the other 3 patients. Mortality rate was 19%; however, survivors generally had nonincapacitating sequelaes. These findings indicate that primary medullary hemorrhage presents with a characteristic syndrome of sudden onset of headache and vertigo with neurological signs that correspond to various combinations of medial and lateral medullary involvement. In those patients who survive, prognosis usually is good.