Transtentorial Herniation Research Articles

The Role for Osmotic Agents in Children with Acute Encephalopathies: A Systematic Review.

Raised intracranial pressure (ICP) is a common complication in children with acute encephalopathies. It compromises cerebral perfusion leading to ischaemia and may cause death when the brainstem is compressed during trans-tentorial herniation. Osmotic agents are widely used to control raised ICP. Their use in children is mainly guided by studies in adults. We carried out this review to determine the best available evidence of the effectiveness of various osmotic agents and their effect on resolution of coma and outcome (neurological sequelae and mortality) in children with acute encephalopathies. We searched literature published between January 1966 and January 2008 on the use of osmotic agents in children aged between 0 and 16 years with acute encephalopathies. We searched Medline, Cochrane Library, EMBASE, Cumulative Index to Nursing and Allied Health Literature and other databases for both published and unpublished literature. We identified four randomized controlled trials (RCTs), three prospective observational studies, two retrospective studies and one case report. The use of hypertonic saline appeared to achieve greater reduction in ICP compared to mannitol, normal saline and ringer's lactate. This effect was sustained when it was given as a continuous infusion. Boluses of glycerol and mannitol achieved transient reduction in ICP. Use of repeated doses of oral glycerol was associated with lower mortality and neurological sequelae when compared to placebo in children with acute bacterial meningitis. Hypertonic saline was associated with lower mortality when compared to mannitol in children with non-traumatic encephalopathies. All agents resulted in reduction of ICP, albeit transient in a number of occasions. A sustained reduction in ICP is desirable and could be achieved by modifying the modes and rates of administration, factors that need further investigation. Hypertonic saline appears to boost cerebral perfusion pressure, an important determinant of outcome in acute encephalopathies. Hypertonic saline appears to achieve greater reduction in ICP than other osmotic agents. Oral glycerol seems to improve outcome among children with acute bacterial meningitis. However, the evidence is not sufficient to guide change of practice. More studies are needed to examine the safest and most efficacious concentrations of the various agents and the most effective routes and rates of administration of these agents.

The Role for Osmotic Agents in Children with Acute Encephalopathies: A Systematic Review

Background - Raised intracranial pressure (ICP) is a common complication in children with acute encephalopathies. It compromises cerebral perfusion leading to ischaemia and may cause death when the brainstem is compressed during trans-tentorial herniation. Osmotic agents are widely used to control raised ICP. Their use in children is mainly guided by studies in adults. Objective - We carried out this review to determine the best available evidence of the effectiveness of various osmotic agents and their effect on resolution of coma and outcome (neurological sequelae and mortality) in children with acute encephalopathies. Selection criteria - We searched literature published between January 1966 and January 2008 on the use of osmotic agents in children aged between 0 and 16 years with acute encephalopathies. Search strategy - We searched Medline, Cochrane Library, EMBASE, Cumulative Index to Nursing and Allied Health Literature and other databases for both published and unpublished literature. Results - We identified four randomized controlled trials (RCTs), three prospective observational studies, two retrospective studies and one case report. The use of hypertonic saline appeared to achieve greater reduction in ICP compared to mannitol, normal saline and ringer’s lactate. This effect was sustained when it was given as a continuous infusion. Boluses of glycerol and mannitol achieved transient reduction in ICP. Use of repeated doses of oral glycerol was associated with lower mortality and neurological sequelae when compared to placebo in children with acute bacterial meningitis. Hypertonic saline was associated with lower mortality when compared to mannitol in children with non-traumatic encephalopathies. Discussion - All agents resulted in reduction of ICP, albeit transient in a number of occasions. A sustained reduction in ICP is desirable and could be achieved by modifying the modes and rates of administration, factors that need further investigation. Hypertonic saline appears to boost cerebral perfusion pressure, an important determinant of outcome in acute encephalopathies. Conclusion - Hypertonic saline appears to achieve greater reduction in ICP than other osmotic agents. Oral glycerol seems to improve outcome among children with acute bacterial meningitis. However, the evidence is not sufficient to guide change of practice. More studies are needed to examine the safest and most efficacious concentrations of the various agents and the most effective routes and rates of administration of these agents.

Brain Stem Hemorrhage Following Burr Hole Drainage for Chronic Subdural Hematoma -Case Report-

A 76-year-old man presented with brain stem hemorrhage after burr-hole drainage for bilateral chronic subdural hematomas. Neuroimaging demonstrated resolution of the transtentorial herniation but also detected new brain stem hemorrhage, manifesting as gait disturbance. He recovered after conservative treatment. Asymmetrical and rapid decompression, which leads to vascular disruption and/or sudden increase in cerebral blood flow, was probably responsible for the secondary brain stem hemorrhage. Therefore, simultaneous and bilateral decompression with a slow rate of evacuation of massive bilateral chronic subdural hematomas is recommended to prevent serious complications such as secondary intracranial hematoma.

Kernohan’s notch phenomenon demonstrated by diffusion tensor imaging and transcranial magnetic stimulation

Kernohan’s notch phenomenon is the ipsilateral hemiplegia caused by compression of the contralateral cerebral peduncle against the tentorial edge by a supratentorial mass. Diffusion tensor imaging (DTI) and transcranial magnetic...

Rapid progression of traumatic bifrontal contusions to transtentorial herniation: A case report.

We report a case of mild to moderate traumatic brain injury in which ICP monitoring or quantitative cerebral perfusion data may have allowed earlier recognition of impending herniation, avoidance of a secondary insult, and ultimately resulted in a better outcome, even though the patient did not meet the standard guidelines of the Brain Trauma Foundation. A thirty-five year old male who presented with traumatic bifrontal contusions and GCS of fourteen and twelve hours later progressed rapidly to having dilated pupils and transtentorial/central herniation over the course of fifteen minutes. The patient was taken emergently for a bifrontal craniectomy. Post operatively he had an acute infarct in the posterolateral left temporal lobe with expected evolution of parenchymal contusions as well as infarcts in the splenium of the corpus callosum, left thalamus and medial right occipital lobe. This case signifies an exception from the guidelines submitted by the Brain Trauma Foundation for intracranial pressure monitoring in patients with severe brain injury.We also point out previous reports which state that in such a patient a more sensitive test for detection would perhaps be quantitative blood flow monitoring, and may have led to a better outcome. We recommend using intracranial pressure monitoring or blood flow measurements to trend patients with bifrontal intraparenchymal contusions and GCS greater than eight to prevent clinically undetected deterioration from transtentorial/central herniation.

Commentary

In this paper, we describe the rare phenomena of descending transtentorial herniation and paradoxical ventriculomegaly due to low pressure hydrocephalus. This resulted as a complication of treatment in a 14 year old male patient, who had undergone multiple ventriculo-peritoneal shunt placements for hydrocephalus after resection of pilocytic astrocytoma. We discuss the etiology of this rare complication and our strategy for treatment. We emphasize the need for strategic placement of programmable shunts to avoid over shunting and associated complications such as tentorial herniation.

An Alternative Treatment for Brain Herniation

Despite the high mortality associated with transtentorial herniation (TTH), meaningful recovery can be achieved with aggressive treatment to reduce

Transtentorial Herniation With Cerebral Infarction and Duret Haemorrhage in a Patient With Spontaneous Intracranial Hypotension: Authors' Reply

Transtentorial Herniation With Cerebral Infarction and Duret Haemorrhage in a Patient With Spontaneous Intracranial Hypotension: Authors' Reply

Atypical Duret haemorrhages seen on computed tomography

We present a case of 80-year-old man who had headache of 1 day duration and gross subdural haemorrhage in the absence of any history of noticeable trauma, leading to descending transtentorial herniation and secondary brain stem haemorrhages called Duret haemorrhages. It is rare to find a Duret haemorrhage on imaging. This case has been presented to highlight the rarity of the condition and the unusual posterior location of the bleed and also the universally fatal nature of these haemorrhages. Relevant literature is reviewed.

More evidence supporting a “brain code” protocol for reversal of transtentorial herniation

The syndrome of transtentorial herniation represents a usually fatal consequence of supratentorial mass lesions.1–3 Rapidly expanding supratentorial mass lesions cause displacement of the temporal lobe medially, leading to herniation of the uncus over the edge of the tentorium cerebri with subsequent compression of the posterior cerebral artery and third nerve.1 The earliest manifestation is a decrease in level of consciousness accompanied by unilateral pupillary dilation (because of third nerve dysfunction). The syndrome progresses to bilateral pupillary dilation, mechanical distortion, and secondary ischemia of the brainstem due to expansion of the primary lesion and impaction of the temporal lobe in the tentorial notch. Classically transtentorial herniation is considered to be a fatal consequence of a supratentorial mass lesion. Small experimental4 and clinical5,6 studies have demonstrated that transtentorial herniation can be reversed with aggressive medical and surgical management, but there is little information on eventual outcomes in such patients. In the current issue of Neurology ®, Koenig et al.7 report the results of using 23.4% sodium chloride in …

EP and brainstem reflexes in patients with large temporal brain tumours

To find possible functional irritation of reflex and sensory neural pathways of the brain and of the brainstem caused by lateralised supratentorial mass shift, 55 patients with large temporal brain tumours were electrophysiological investigated. In this patients the electrical (BR) and mechanical (GR) elicited blinking reflex, the jaw-reflex (MR) were derived as well, as the acoustic (BAEP) the somato-sensory (MSSEP) and the flash elicited visual (f-VEP) evoked potential. The infratentorial generated BR, GR and BAEP showed very frequently (>3/4 of the cases) slight pathological changes (pontine and ponto-bulbar). In contrast to this, the predominantly in tentorial level (mesencephalic) generated MR, and also supratentorial generated cortical MSSEP and the f-VEP indeed showed less frequent but more marked signal changes than the BR, GR and BAEP. On grounds of the constellation of the electrophysiological findings is to assume, that the mass-shift of the brain lead very early to a slight infratentorial brainstem irritation due to an cranio-caudal brainstem displacement and later to a marked irritation of the tentorial and supratentorial signal generators, because for the present there is (supratentorial) more space for unhindered mass-displacement. After the space is occupied the immediateness of the tissue irritation lead to more intensive signal changes than those of the infratentorial generated electrophysiological signals. The last remain for long time unchanged up to the time point of transtentorial and tonsillar herniation.

A fatal outcome in a patient with glioblastoma multiforme after receiving high-dose methotrexate

The most common adult primary brain tumor is glioblastoma multiforme (GBM). Current treatment is surgical resection, adjuvant radiation and chemotherapy, which can extend the median survival 20-36 weeks (Mansky et al. Central nervous system tumors. In Abraham J, Allegra CJ, Gulley J, eds. Bethesda Handbook of clinical oncology, 2nd edn. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins, 2000: 440-2; Knox S. Intracranial tumors. In Pillot G, Chantler M, Magiera H, Peles S, et al., eds. The Washington Manual Hematology and Oncology Subspecialty Consult. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins, 2004: 204-6.). But treatment efficacy is limited, mandating the exploration of more effective treatments. We report on a patient with GBM treated as per a clinical protocol with high-dose methotrexate (12 g/m(2)), who expired within hours after the initiation of treatment secondary to transtentorial herniation. Although it is not completely clear what caused the patient's herniation, we think that high-dose methotrexate therapy may have played a crucial role. We suggest that high-dose methotrexate should be used cautiously in patients with GBM.

Reversal of transtentorial herniation with hypertonic saline

To evaluate the role of 23.4% saline in the management of transtentorial herniation (TTH) in patients with supratentorial lesions. Consecutive patients with clinically defined TTH treated with 23.4% saline (30 to 60 mL) were included in a retrospective cohort. Factors associated with successful reversal of TTH were determined. Seventy-six TTH events occurred in 68 patients admitted with intracerebral hemorrhage (n = 29), subarachnoid hemorrhage (n = 16), stroke (n = 8), brain tumor (n = 8), subdural hematoma (n = 5), epidural hematoma (n = 1), and meningitis (n = 1). In addition to 23.4% saline, TTH management included hyperventilation (70% of events), mannitol (57%), propofol (62%), pentobarbital (15%), ventriculostomy drainage (27%), and decompressive hemicraniectomy (18%). Reversal of TTH occurred in 57/76 events (75%). Intracranial pressure decreased from 23 +/- 16 mm Hg at the time of TTH to 14 +/- 10 mm Hg at 1 hour (p = 0.002), and 11 +/- 12 mm Hg at 24 hours (p = 0.001) among 22 patients with intracranial pressure monitors. Reversal of TTH was predicted by a >/=5 mmol/L rise in serum sodium concentration (p = 0.001) or an absolute serum sodium of >/=145 mmol/L (p = 0.007) 1 hour after 23.4% saline. Adverse effects included transient hypotension in 13 events (17%); no evidence of central pontine myelinolysis was detected on post-herniation MRI (n = 18). Twenty-two patients (32%) survived to discharge, with severe disability in 17 and mild to moderate disability in 5. Treatment with 23.4% saline was associated with rapid reversal of transtentorial herniation (TTH) and reduced intracranial pressure, and had few adverse effects. Outcomes of TTH were poor, but medical reversal may extend the window for adjunctive treatments.

Combined internal uncusectomy and decompressive craniectomy for the treatment of severe closed head injury: experience with 80 cases

Transtentorial brain herniation is a major cause of morbidity and death following severe closed head injury. The purpose of this study was to evaluate the efficacy of selective uncoparahippocampectomy and tentorial splitting as an adjuvant method of treating otherwise uncontrollable elevated intracranial pressure (ICP) while attempting to prevent or minimize the devastating consequences caused by transtentorial herniation. The authors retrospectively reviewed data from a series of 80 consecutive cases of severe closed head injury (Glasgow Coma Scale [GCS] score < 8) treated in their neurosurgical unit. All patients had elevated ICP and downward tentorial herniation, as documented with ICP monitoring, and clinical examination and computed tomography, respectively. Given the evidence of acute and ongoing neurological deterioration, all patients were treated with selective uncoparahippocampectomy and tentorial edge incision followed by wide decompressive craniectomy and duraplasty. All injuries were caused by blunt trauma with signs of acute and/or progressive increased ICP causing downward transtentorial herniation. Fifty-eight patients were male and 22 were female with a mean age of 35 years and a mean preoperative GCS score of 5. Based on the current American Association of Neurological Surgeons guidelines for head trauma, an intraparenchymal ICP device (Camino, Integra) was placed in all patients who had a GCS score < 8, and ICP was consistently > 20 cm H2O. Whenever possible, risks and benefits were explained to family members, and then surgery was performed within 3-16 hours (median 6 hours). At a mean follow-up of 30 months, the outcome was favorable (Glasgow Outcome Scale [GOS] score of 4 or 5) in 60 patients (75%) and unfavorable (GOS score of 3) in 8 (10%), whereas the remaining 12 patients (15%) died at some point during the postoperative course. There was no survivor patient in a vegetative state. A younger age had a significant effect on positive outcome (p < 0.0005), as did an earlier operation (p < 0.04). The preoperative neurological status as assessed using the GCS as well as pupillary reactivity had no significant effect on outcome (p = 0.054 and p > 0.05, respectively). A selective uncoparahippocampectomy with a tentorial edge incision and a wide decompressive craniectomy with duraplasty can be an effective adjuvant form of aggressive treatment to improve outcome in patients with severe closed head injury, especially in those who are younger if they are treated promptly.

Transtentorial Herniation with Cerebral Infarction and Duret Haemorrhage in a Patient With Spontaneous Intracranial Hypotension

Transtentorial Herniation with Cerebral Infarction and Duret Haemorrhage in a Patient With Spontaneous Intracranial Hypotension

The Reversal Sign

HomeRadiologyVol. 245, No. 3 PreviousNext Signs in ImagingThe Reversal SignEoin C. KavanaghEoin C. KavanaghAuthor Affiliations1From the Division of Neuroradiology, Department of Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada. Received January 22, 2005; revision requested March 23; revision received March 25; final version accepted June 15.Address correspondence to the author, Department of Musculoskeletal Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (e-mail: [email protected]).Eoin C. KavanaghPublished Online:Dec 1 2007https://doi.org/10.1148/radiol.2453050112MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 Cohen RA, Kaufman RA, Myers PA, Towbin RB. Cranial computed tomography in the abused child with head injury. AJR Am J Roentgenol 1986; 146: 97–102. Crossref, Medline, Google Scholar2 Han BK, Towbin RB, De Courten-Myers G, McLaurin RL, Ball WS Jr. Reversal sign on CT: effect of anoxic/ischemic cerebral injury in children. AJNR Am J Neuroradiol 1989;10:1191–1198. Medline, Google Scholar3 Myers RE. Experimental models of perinatal brain damage: relevance to human pathology. In Gluck L, ed. Intrauterine asphyxia and the developing brain. Chicago, Ill: Yearbook Medical, 1977; 37–97. Google Scholar4 Chen CJ. Central structure preservation of the reversal sign. Neuroradiology 1999;41:946–948. Crossref, Medline, Google Scholar5 Shewmon DA, Fine M, Masdeu JC, Palacios E. Postischemic hypervascularity of infancy: a stage in the evolution of ischemic brain damage with characteristic CT scan. Ann Neurol 1981;9:358–365. Crossref, Medline, Google Scholar6 Rao P, Carty H, Pierce A. The acute reversal sign: comparison of medical and non-accidental injury patients. Clin Radiol 1999;54:495–501. 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Crossref, Medline, Google ScholarArticle HistoryPublished in print: 2007 FiguresReferencesRelatedDetailsCited ByTextbook of Pediatric NeurosurgeryJohannes NicholaasEnslin, AnthonyFigaji2020An Ominous Finding: Cerebellar Reversal SignIndar KumarSharawat, AnanthanarayananKasinathan, LesaDawman2020 | Neuropediatrics, Vol. 51, No. 05White Cerebellum Sign: A Poor Prognostic SignNeenaBaby, PercivalGilvaz, Aneesh MangalasserilKuriakose2019 | Pediatric Neurology, Vol. 101Neuroimaging of pediatric abusive head traumaMaryRolfes, JulieGuerin, JustinBrucker, PeterKalina2019 | Applied RadiologyAcute Radiologic Manifestations of America’s Opioid EpidemicDavid D. B. Bates, Katherine Gallagher, HeiShun Yu, Jennifer Uyeda, Akira M. Murakami, Bindu N. Setty, Stephan W. Anderson, Mariza O. 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Sudden Death in Toddlers with Viral Meningitis, Massive Cerebral Edema, and Neurogenic Pulmonary Edema and Hemorrhage: Report of Two Cases

Viral (lymphocytic) meningitis typically does not cause sudden death, especially in the absence of severe inflammation in the brain or other organs. We report 2 toddlers with clinical evidence of a viral infection who died unexpectedly and were found at autopsy to have lymphocytic meningitis associated with severe brain edema, transtentorial herniation, neurogenic pulmonary edema and hemorrhage, and cardiomegaly. Influenza A virus, demonstrated in tracheal epithelium by immunocytochemistry, is the presumed cause of the mild meningitis in 1 case; adenovirus was cultured from swabs of the brain and anus in the 2nd case. Current concepts of neurogenic pulmonary edema and acute cardiac dysfunction associated with intracranial disease are discussed in considering the mechanism of sudden death in these toddlers. These cases emphasize the possibility that mild intracranial viral infections may be a rare cause of sudden death via lethal cardiopulmonary complications. They also underscore the importance of a comprehensive autopsy, including detailed neuropathologic examination and viral testing, in determining of the cause of unexpected death in toddlers.

Brain Lobectomy for Severe Head Injuries is not a Hopeless Procedure

Posttraumatic transtentorial herniation or intractable intracranial hypertension are ominous signs, and are associated with very poor outcomes. Aggressive procedures, such as brain lobectomies, may benefit some of these patients. The published experience with brain lobectomies is very limited. Retrospective study of head injury patients with focal brain lesions and intractable intracranial hypertension or herniation who underwent partial or anatomic brain lobectomies. The following parameters were included in the analysis: age, gender, mechanism of injury, hypotension at admission, initial Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale for head, chest, and abdomen, Injury Severity Score, time from admission to operation, type of brain lobectomy, intensive care unit and hospital stays, survival, and Glasgow Outcome Score. Stepwise logistic regression analysis was used to identify independent risk factors for mortality and functional outcomes. During the 13-year study period, there were 183 patients who underwent brain lobectomy for traumatic injuries. Eighty-eight patients (48.1%) underwent frontal lobectomy, 67 (36.6%) temporal lobectomy, and the remaining 28 (15.3%) other or combination lobectomies. The mean follow-up was 22 days. There were 50 deaths (mortality 27.3%). Excluding patients with major extracranial injuries, there were 47 deaths (26.9%). Patients with blunt trauma had a significantly higher mortality than those with penetrating trauma had (33.1% vs. 12.0%, p = 0.005). Among the risk factors studied, blunt injury mechanism was identified as the only risk factor for mortality. Overall, 48% of the 133 survivors had good functional outcomes, and 51.9% had poor functional outcomes (including 15.0% with persistent vegetative state). Multiple-response logistic regression identified blunt trauma, low initial GCS score, and frontal lobectomy as independent risk factors for poor outcomes. Selected severe head injury patients with focal brain lesions and intractable intracranial hypertension or herniation may benefit from brain lobectomies. The survival and functional outcomes after this procedure are acceptable. Blunt trauma, low initial GCS score, and frontal lobectomies are significant risk factors for poor outcomes.

Réanimation des patients traumatisés crâniens graves

Severe brain injuries, most often occurring in young subjects, are a major source of lost work years. These injuries are medical and surgical emergencies. Prehospital management of severe brain injuries requires intubation and mechanical ventilation aimed at normal arterial carbon dioxide pressure. Signs of transtentorial herniation: Uni- or bilateral mydriasis requires immediate perfusion of 20% mannitol or hypertonic sodium chloride. Neurological disorders after head injury justify emergency cerebral computed tomography. The presence of a mass syndrome or signs of transtentorial herniation are in principle indications for surgery. Specialized hospital management is essential. In the case of refractory intracranial hypertension, the cerebral perfusion pressure and osmotherapy should be adapted to the volume of the cerebral contusion. The use of deep hypothermia and barbiturates should be minimized as much as possible. Magnetic resonance imaging makes it possible to identify the cerebral lesions.

Inadvertent hyponatremia leading to acute cerebral edema and early evidence of herniation

For years, the maintenance of normal or supranormal serum sodium (Na) concentrations has been believed to be beneficial in brain injuries. Recently published guidelines for cerebral trauma recommend the use of hypertonic saline to achieve hypernatremia for the management of increased intracranial pressure and these standards are generally practiced across most diseases in neurocritical care including stroke, hemorrhage and tumors. Severe hyponatremia has long been known to be detrimental, but objective evidence for the harm of mild hyponatremia as a secondary injury has been scarce. In this case report, we describe a child with aneurysmal subarachnoid hemorrhage who had a sudden, inadvertent decrease in serum Na (128 meq/l) that was associated with a deterioration of her neurological examination and evidence of early transtentorial herniation on emergent brain CT scan. These findings were quickly reversed after the serum Na was corrected. This report emphasizes that close monitoring of serum Na and osmolarity in acute head injured children is important, and provides evidence that alterations of these parameters is a substantial risk for cerebral edema in children with evolving brain injuries and briefly reviews the literature regarding the risks of hyponatremia in children.