Improvement of Respiratory Depression in a Patient with Primary Medullary Hemorrhage Following Removal of Hematoma in the Half-sitting Position

Abstract

Primary medullary hemorrhage is a rare event that may result in ataxic respiration. Although it remains controversial whether primary medullary hemorrhage should be managed conservatively or surgically, recent advancements in neuroimaging and microsurgical techniques have shown promise for improving outcomes and prognosis following surgery. The present report discusses the case of a 70-year-old woman admitted to our institution due to sudden-onset nausea and vomiting. The patient underwent surgical removal of a right medullary hematoma for the treatment of daytime respiratory depression and nocturnal apnea while in the half-sitting position. Following surgery, her spontaneous respiration improved, and she was discharged with independent gait. Despite the risk of venous air embolism, accumulating evidence suggests that the half-sitting position is suitable for brainstem surgery because gravity-assisted blood and irrigation drainage from the surgical field allows for cleaner dissection and reduces the need for bipolar coagulation.

Keywords

primary medullary hemorrhage - respiratory depression - half-sitting position

• References

• 1 Kwon HM, Park JM, Lee JY, Yoon BW. Primary medullary hemorrhage associated with hypertension. J Clin Neurol 2005; 1 (02) 177-179
• 2 Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB. The Stroke Data Bank: design, methods, and baseline characteristics. Stroke 1988; 19 (05) 547-554
• 3 Barinagarrementeria F, Cantú C. Primary medullary hemorrhage. Report of four cases and review of the literature. Stroke 1994; 25 (08) 1684-1687
• 4 Biller J, Gentry LR, Adams Jr HP, Morris DC. Spontaneous hemorrhage in the medulla oblongata: clinical MR correlations. J Comput Assist Tomogr 1986; 10 (02) 303-306
• 5 Cohen HCM, Tucker WS, Humphreys RP, Perrin RJ. Angiographically cryptic histologically verified cerebrovascular malformations. Neurosurgery 1982; 10 (6 Pt 1): 704-714
• 6 Kempe LG. Surgical treatment of an intramedullary haematoma simulating Wallenberg's syndrome. J Neurol Neurosurg Psychiatry 1964; 27: 78-80
• 7 Lee CC, Ryu SJ. Primary medullary hemorrhage: report of a case. J Formos Med Assoc 1992; 91 (05) 552-554
• 8 Mazagri R, Shuaib A, Denath FM. Medullary hemorrhage causing vertigo and gaze nystagmus. Ear Nose Throat J 1992; 71 (09) 402-403
• 9 Mastaglia FL, Edis B, Kakulas BA. Medullary haemorrhage: a report of two cases. J Neurol Neurosurg Psychiatry 1969; 32 (03) 221-225
• 10 Neumann PE, Mehler MF, Horoupian DS. Primary medullary hypertensive hemorrhage. Neurology 1985; 35 (06) 925-928
• 11 Shuaib A. Benign brainstem hemorrhage. Can J Neurol Sci 1991; 18 (03) 356-357
• 12 Lee SU, Kim HJ, Kang BS, Kim JS. Isolated medullary hemorrhage: clinical features in eleven consecutive patients. J Stroke 2017; 19 (01) 111-114
• 13 Posner JB, Saper CB, Schiff N, Plum F. Plum and Posner's Diagnosis of Stupor and Coma. 4th ed. New York, NY: Oxford University Press; 2007: 38-39
• 14 Shrestha BK, Ma L, Lan Z, Li H, You C. Surgical management of spontaneous hypertensive brainstem hemorrhage. Interdiscip Neurosurg 2015; 2: 145-148
• 15 Mangiardi JR, Epstein FJ. Brainstem haematomas: review of the literature and presentation of five new cases. J Neurol Neurosurg Psychiatry 1988; 51 (07) 966-976
• 16 Ammirati M, Lamki TT, Shaw AB, Forde B, Nakano I, Mani M. A streamlined protocol for the use of the semi-sitting position in neurosurgery: a report on 48 consecutive procedures. J Clin Neurosci 2013; 20 (01) 32-34
• 17 Saladino A, Lamperti M, Mangraviti A. , et al. The semisitting position: analysis of the risks and surgical outcomes in a contemporary series of 425 adult patients undergoing cranial surgery. J Neurosurg 2017; 127 (04) 867-876