Pontine Stroke

What is a pontine stroke?

A pontine stroke (infarction) happens when there’s a blood flow blockage to a part of your brainstem called the pons. It’s a type of ischemic stroke. The blockage may be sudden (acute) or develop over time (chronic).

The pons is the largest portion of your brainstem. It has several important functions.

Other names for a pontine stroke include:

• Brainstem stroke or infarction.
• Pons stroke or infarction.

A pontine stroke is a medical emergency, and early treatment is crucial.

How common are pontine strokes?

Strokes are very common. But compared to other types of strokes, pontine strokes are less common.

Pontine strokes represent about 7% of all ischemic strokes. About 691,000 people in the U.S. experience an ischemic stroke each year. That means about 48,000 people in the U.S. have a pontine stroke each year.

What are the symptoms of a pontine stroke?

There are several possible symptoms — and groups of symptoms — that can develop from a pontine stroke. It’s important to note that pontine stroke symptoms are slightly different from typical stroke symptoms.

Symptoms of a pontine stroke may include:

• Muscle weakness on one side of your body (hemiparesis).
• Weakness and droopiness on one or both sides of your face (facial nerve palsy).
• Abnormal sensations (like numbness or pins and needles) on one side of your face.
• Abnormal sensations on one side of your body (hemisensory loss).
• Slurred speech (dysarthria).
• Difficulty swallowing (dysphagia).
• Difficulty breathing.
• Loss of coordination or balance (ataxia).
• A spinning sensation (vertigo).
• Hearing loss.
• Uncontrollable crying or laughing (pseudobulbar affect).
• Paralysis in both arms and legs (quadriplegia).
• Loss of consciousness.

Eye and vision symptoms may include:

• Double vision when viewing objects side by side (due to sixth nerve palsy).
• Repetitive, uncontrolled eye movements (nystagmus).
• Inability to move both eyes together in a single direction (conjugate gaze palsy).
• Issues with blinking.

Get medical help immediately if you or a loved one develops any of these symptoms. Pontine strokes are life-threatening and can cause irreversible damage.

Types of pontine strokes

You can have a blood flow blockage in different parts of your pons, resulting in different types of pontine strokes. The different types tend to cause different symptoms, though many symptoms overlap. Healthcare providers use anatomical terms to describe the different types.

For example:

• A medial pontine stroke (near the middle of your pons) typically causes weakness on one side of your body, eye muscle paralysis and horizontal gaze palsy.
• A lateral pontine stroke (on either side of your pons) typically causes hemisensory loss on the opposite side of your body and ataxia. You could have a bilateral (affecting both sides) or unilateral (affecting one side) pontine stroke.
• A caudal pontine stroke (near the back of your pons) typically causes facial nerve palsy, hearing loss and vertigo.

What causes a pontine stroke?

A pontine stroke happens when there’s a blockage in the blood flow to your pons. Two common causes of a blockage include:

• Small artery disease: Long-standing high blood pressure or diabetes can damage small arteries in your pons, leading to long-term blood flow restriction and an eventual blockage (stroke). This is the most common cause.
• Large artery atherosclerosis: Atherosclerosis is the hardening of your arteries due to gradual plaque buildup. Buildup in the larger arteries that lead to your brain (vertebral or basilar artery) can block blood flow to the smaller arteries of your pons.

What are the risk factors for pontine stroke?

The main risk factors for pontine stroke are the same as those for ischemic stroke: high blood pressure and diabetes. These conditions can damage your blood vessels, including those in your pons.

Other risk factors include:

• Smoking.
• High cholesterol.
• History of ischemic heart disease (heart issues caused by narrowed heart arteries).
• Blood clotting disorders (hypercoagulable states).
• Vasculitis.

If you have any of these risk factors, it’s important to see your healthcare provider regularly to make sure your treatment plan is working well.

How is pontine stroke diagnosed?

You should go to an emergency room (ER) as soon as possible if you develop stroke symptoms. There, a healthcare provider will do several tests and assessments to help diagnose a pontine stroke and check your health. These may include:

• Checking your blood pressure and heart rate.
• Checking your breathing (respiratory function).
• Physical exam and medical history.
• Neurological exam. This can pinpoint telltale signs of a stroke and potentially which part of your brain it’s affecting.
• Brain imaging tests, like a CT scan and/or MRI scan. These tests can confirm that the stroke is in your pons.

The provider may order additional tests, like blood tests and an EKG, to check other aspects of your health.

What is the treatment for a pontine stroke?

The highest treatment priority for a pontine stroke is restoring circulation (blood flow) to your pons. That’s because restoring circulation quickly can prevent permanent damage or at least limit a stroke’s severity. Once again, it’s essential to get to a hospital as soon as possible if you’re having stroke symptoms so you can get treatment quickly.

Restoring circulation usually involves a type of medication called thrombolytics. It may also involve a procedure called a mechanical thrombectomy to remove the blood clot if you have a large artery blockage.

Other goals of treatment include:

• Preventing complications. Your healthcare team may give you various other treatments to prevent or treat complications.
• Rehabilitation to improve neurological side effects or complications.
• Strategies for preventing additional strokes, like medications, eating changes and increased physical activity.

Pontine stroke rehabilitation

Stroke rehabilitation is a major part of recovery for most people who have a stroke. It can take many forms depending on your symptoms, including:

• Speech therapy: This can help you regain language and speaking abilities and improve your ability to control muscles that help you breathe, eat, drink and swallow.
• Physical therapy: This can help you improve or regain the ability to use your hands, arms, feet and legs. This can also help with balance issues, muscle weakness and more.
• Occupational therapy: This can help retrain your brain so you can go about your typical daily activities, like using utensils to eat and putting on clothes.
• Sensory re-education: This helps to retrain or stimulate your senses. For example, you may experience and identify different textured objects, vibrations, pressures and temperatures.
• Cognitive therapy: This can be helpful if you’re having memory problems. It can also help if you have difficulty with activities that require focus or concentration that you could do before.

How can I prevent a pontine stroke?

Pontine strokes aren’t always preventable. But you can work with your healthcare provider to help manage any stroke risk factors you may have. Management strategies may include:

• Blood pressure management with a goal of 140/90 mmHg or lower. Your provider may recommend medication and/or activity and eating changes.
• High cholesterol (dyslipidemia) treatment, like increased physical activity, food changes and/or statins.
• Diabetes management with the goal of maintaining an A1C of 7% or lower.
• Quitting smoking, which may involve psychotherapy (talk therapy) and nicotine replacement therapy (NRT).
• Changes to your eating plan, like following the DASH diet or Mediterranean diet.
• Regular physical activity for 40 minutes a day for three to four days a week.
• Reaching and/or maintaining a healthy weight.
• Taking anticoagulants (aspirin or warfarin) if you have atrial fibrillation (Afib).

What is the prognosis for people with a pontine stroke?

The prognosis (outlook) for people with a pontine stroke depends on several factors, like:

• Where the stroke happened in your pons.
• The severity of the stroke.
• How quickly you received treatment.
• Your overall health and age.

For example, unilateral (affecting one side) pontine strokes typically have better outcomes than bilateral (affecting both sides) and caudal (affecting the back of your pons) pontine strokes.

Your healthcare team will give you a better idea of what recovery will look like after a pontine stroke. Lean on your loved ones to help with raising any questions or concerns.

What are the long-term effects of a pontine stroke?

A pontine stroke can cause several long-term or permanent complications. This is because your brainstem, which includes your pons, is a vital brain structure with many important functions. Your risk of experiencing complications depends on many factors, like the type of pontine stroke and its severity.

Complications can include:

• Permanent brain damage.
• Difficulty eating that requires tube feeding.
• Loss of bladder control (urinary incontinence) requiring the use of a urinary catheter.
• Long-lasting muscle weakness, which could result in frequent falls.
• Post-stroke depression.
• Complications due to long-term bed rest, like bedsores and deep vein thrombosis (DVT).
• Long-term disability.
• Locked-in syndrome.
• Aspiration pneumonia due to pseudobulbar palsy or locked-in syndrome.
• Death.

What questions should I ask my healthcare provider?

If you (or a loved one) had a pontine stroke, it may help to ask your healthcare provider the following questions:

• What type of pontine stroke did I have?
• What brain and body functions did the stroke impact?
• What will my recovery be like? What are the next steps for my care?
• What types of rehabilitation will I need?
• What will I be able to do in the next few months?
• What can I expect one year from now?
• What skills do my loved ones and I need to take care of me?
• What services and resources can help me and my loved ones?
• What are my risk factors for another stroke?