Impending Uncal Herniation Research Articles

Near-Infrared Spectroscopy–Guided Hyperventilation for Transient Intracranial Pressure Control during Anesthesia Induction in a Patient with Impending Uncal Herniation

Near-infrared spectroscopy (NIRS) is known to determine the adequacy of regional cerebral oxygen supply. NIRS values during anesthetic induction depends upon various factors such as anesthetic agents, inspired oxygen fraction, blood carbon dioxide levels and systemic blood pressure. Also high intracranial pressure (ICP) can lead to reduced NIRS values, secondary to increased cerebral vascular resistance induced decrease in cerebral blood flow. However optimal hyperventilation instituted as a bridge to definitive ICP management is difficult to ascertain as hypocapnia due to poorly titrated hyperventilation can potentially worsen ICP. Here we describe a novel application of NIRS-guided hyperventilation during anesthesia induction in a brain tumor patient with raised ICP features and impending uncal herniation as suggested by computed tomography (CT) scan, with ipsilateral baseline reduced NIRS values. These ipsilateral NIRS values further reduced significantly during anesthesia induction even before profound bradycardia occurred, which promptly improved to baseline following hyperventilation.

Endovascular treatment of concomitant innominate and subclavian artery injury with pseudoaneurysms from a gunshot wound in a polytrauma patient

Introduction Injury of the innominate artery (IA) is associated with high mortality and morbidity, such as a major neurologic event. The aim of this case report was to describe an example of prioritization in polytrauma management by applying endovascular intervention in a difficult case with impending uncal herniation, extensive cerebral infarction, and large pseudoaneurysm from concomitant innominate and right subclavian artery injuries. Case Report A 34-year-old woman sustained a gunshot wound to her upper chest that lodged in the anterior triangle of her neck and presented with tension pneumothorax and cardiac arrest, which was successfully resuscitated. Subsequently she developed drowsiness and left hemiparesis, and computerized tomography demonstrated a large right cerebral hemisphere and left cerebellar region infarction with impending uncal herniation and pseudoaneurysms from the IA and proximal right subclavian artery. After emergency craniectomy to avert herniation, endovascular treatment was performed to facilitate vessel repair due to anatomical difficulty and the patient’s unstable condition. She was discharged home 3 weeks after operation, and 2 months postoperatively, she was neurologically intact with no evidence of endoleakage or pseudoaneurysm. Conclusion In such a complex polytrauma case, correct prioritization of interventions is crucial to obtaining the best outcomes, and the Endovascular Resuscitation and Trauma Management protocol can be applied as an alternative treatment protocol with good results.

Case Report: Frontalis sign for early bedside consideration of impending uncal herniation.

It is prudent to have early diagnosis and timely management of uncal herniation for better management of neurosurgical patients. There are several clinical and radiological armamentariums that aid in early recognition of the condition. Through this case report, we try to highlight a simple bedside clinical sign that can be a valuable adjunct in early recognition of the impending uncal herniation especially in scenarios wherein it is difficult to assess the pupillary size and reactivity correctly. The improvement in the sign also confirms the resolution of the mass effect in the postoperative period. This is especially helpful for doctors working in the periphery or in resource restrained areas, for a timely referral of the patient to tertiary centre.

Case Report: Frontalis sign for early bedside diagnosis of impending uncal herniation

It is prudent to have early diagnosis and timely management of uncal herniation for better management of neurosurgical patients. There are several clinical and radiological armamentarium that aid in early recognition of the condition. Through this case report, we try to highlight a simple bedside clinical sign that can help in early recognition of the impending uncal herniation. The improvement in the sign also confirms the resolution of the mass effect in the postoperative period. This is especially helpful for doctors working in the periphery or in resource restrained areas, for a timely referral of the patient to tertiary centre.

Expanding contralateral epidural hematoma causing acute intraoperative brain swelling

Expanding contralateral epidural hematoma causing acute intraoperative brain swelling

Craniectomía descompresiva en encefalitis herpética: Caso clínico

abstraCt Decompressive craniectomy in herpes simplex encephalitis. Clinical case introduction: the morbidity and mortality of herpes simplex encephalitis (HSE) have decreased with the use of acyclovir. However, some patients develop focal hemorrhagic necrosis and edema in the temporal lobe, with a subsequent elevation of intracranial pressure. Clinical cases: We report the clinical outcomes of two children with HSE who developed severe intracranial hypertension and impending uncal herniation refractory to profound sedation, osmotic agents and moderate hyperventilation. Decompressive craniectomy allowed an effective control of intracranial pressure and a favorable neurological outcome at discharge in both patients. Conclusions: Decompressive craniectomy could be considered as a rescue treatment strategy in patients with life-threatening intracranial hypertension due to severe herpetic encephalitis. (Key words : Herpes, encephalitis, craniectomy, children).Rev Chil Pediatr 2012; 83 (5): 468-473

Viral meningoencephalitis: a review of diagnostic methods and guidelines for management

Viral encephalitis is a medical emergency. The prognosis depends mainly on the pathogen and host immunologic state. Correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury. We searched the literature from 1966 to 2009. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear, we have stated our opinion as good practice points. Diagnosis should be based on medical history and examination followed by CSF analysis for protein and glucose levels, cellular analysis, and identification of the pathogen by polymerase chain reaction amplification (recommendation level A) and serology (level B). Neuroimaging, preferably by MRI, is essential (level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be performed immediately, LP should be delayed only under unusual circumstances. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. Patients must be hospitalized with easy access to intensive care units. Specific, evidence-based, antiviral therapy, acyclovir, is available for herpes encephalitis (level A) and may also be effective for varicella-zoster virus encephalitis. Ganciclovir and foscarnet can be given to treat cytomegalovirus encephalitis, and pleconaril for enterovirus encephalitis (IV class evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective, and their use is controversial, but this important issue is currently being evaluated in a large clinical trial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management.

Rapid Spontaneous Resolution of Neurological Signs and Cerebral Herniation Caused by Intracerebral Hemorrhage -Case Report-

A 47-year-old man presented with sudden consciousness disturbance and left hemiplegia caused by intracerebral hemorrhage. Initial computed tomography (CT) showed a massive subcortical right temporoparietal lobe hematoma and signs of impending uncal herniation. However, he became alert and his hemiplegia improved considerably in the course of 2 hours, so conservative treatment was preferred over surgical intervention. Follow-up CT acquired on the next day revealed dramatic diminution of the intracerebral hemorrhage. Small intracerebral hemorrhages occasionally produce transient symptoms with or without disappearance of the hematoma, but the present patient had a large hematoma that decreased in size within a short time with rapid improvement of the symptoms attributed to the hematoma. The mechanism underlying the diminution of the hematoma may be related to redistribution by cerebrospinal fluid flow.

Intracerebral Cavernous Malformation Induced by Radiosurgery-Case Report-

A 37-year-old man was treated for lung cancer by chemo-radiation therapy. Subsequently, magnetic resonance (MR) imaging identified a ring-enhanced lesion in the left temporal lobe. Gamma knife radiosurgery was performed under a diagnosis of brain metastasis. Nevertheless, MR imaging showed regrowth of the tumor 1 year later, so radiosurgery was repeated on the same lesion. Two years after the first radiosurgery, MR imaging revealed an irregularly enhanced lesion with increasing perifocal edema in the left temporal lobe. Emergency surgery was performed under a diagnosis of impending uncal herniation. The histological diagnosis was cavernous malformation. This case demonstrates that gamma knife radiosurgery can cause radiation-induced cavernous malformation.

Viral encephalitis: a review of diagnostic methods and guidelines for management

Viral encephalitis is a medical emergency. The spectrum of brain involvement and the prognosis are dependent mainly on the specific pathogen and the immunological state of the host. Although specific therapy is limited to only several viral agents, correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury in survivors. We searched MEDLINE (National Library of Medicine) for relevant literature from 1966 to May 2004. Review articles and book chapters were also included. Recommendations are based on this literature based on our judgment of the relevance of the references to the subject. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. Diagnosis should be based on medical history, examination followed by analysis of cerebrospinal fluid for protein and glucose contents, cellular analysis and identification of the pathogen by polymerase chain reaction (PCR) amplification (recommendation level A) and serology (recommendation level B). Neuroimaging, preferably by magnetic resonance imaging, is an essential aspect of evaluation (recommendation level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be obtained at the shortest span of time it should be delayed only in the presence of strict contraindications. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. All encephalitis cases must be hospitalized with an access to intensive care units. Supportive therapy is an important basis of management. Specific, evidence-based, anti-viral therapy, acyclovir, is available for herpes encephalitis (recommendation level A). Acyclovir might also be effective for varicella-zoster virus encephalitis, gancyclovir and foscarnet for cytomegalovirus encephalitis and pleconaril for enterovirus encephalitis (IV class of evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective and their use is controversial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management.

Uncommon complication of herpes simplex encephalitis

A 9-year-old-girl who had herpes simplex encephalitis developed impending uncal herniation requiring surgical decompression. This case highlights the development of an uncommon complication despite the early initiation of treatment with acyclovir.

Herpes simplex encephalitis: the role of surgical decompression

BACKGROUND The role of acyclovir for the treatment of herpes simplex encephalitis has been well documented, but the role of surgical decompression for herpes simplex encephalitis has only rarely been mentioned. The authors report two cases of herpes simplex encephalitis that involved surgical decompression. CASE DESCRIPTION In the first case, a therapeutic regimen of acyclovir was begun on the 11 th day of the clinical course, and surgical decompression was performed because of impending uncal herniation on the 13 th day. In the second case, a therapeutic regimen of acyclovir was begun on the third day of the disease’s clinical course, and surgical decompression was performed because of impending uncal herniation on the 11 th day. Both patients had good neurological outcomes and were seizure-free 12 months after their surgical procedures. CONCLUSION We conclude that, for patients with herpes simplex encephalitis, it is important for the clinician to detect deterioration of consciousness because of the mass effect caused by the disease-associated inflammatory process as early as is possible. Surgical decompression is indicated for impending uncal herniation or intolerable increased intracranial pressure. Such surgery can contribute to an improved outcome for patients with herpes simplex encephalitis.

A SIGN OF INTRACRANIAL MASS WITH IMPENDING UNCAL HERNIATION.

Introduction AMASS lesion of brain may increase intracranial pressure and distort normal anatomical relationships. The well-known syndrome of ipsilateral dilatation of pupil and contralateral hemiplegia is associated with actual or incipient uncal herniation, and thus might indicate compression of oculomotor nerve or midbrain.1-3Sometimes there is an initial miosis which might be due to hyperexcitability early in course of compression; mydriasis develops later and could reflect loss of function from further compression.4-6 A nonreactive, dilated pupil ipsilateral to a mass lesion was first described by Hutchinson in 1867.7A curious historical footnote is that later he emphasized bilateral mydriasis, and in 1898 wrote about the non-significance of a (unilateral) fixed and dilated pupil.8MacEwen9should be credited with an early correlation of unilateral mydriasis with a mass lesion and, significantly, loss of consciousness. The purpose of this article is