Transtentorial Herniation Research Articles

Paradoxical fixed dilatation of the contralateral pupil as a false-localizing sign in intraparenchymal frontal hemorrhage

Unilateral fixed pupillary dilatation represents an important clinical sign of transtentorial herniation of an ipsilateral mass lesion. Rarely the contralateral pupil is affected to produce a false-localizing sign. Two cases of this paradoxical contralateral fixed pupillary dilatation involving intra-axial lesions have been reported. We report a case of a 33-year-old man with a left frontal intraparenchymal hemorrhage who developed a false localizing fixed dilatation of his right pupil, which resolved after craniotomy and evacuation of the clot. The possible mechanisms of contralateral third nerve palsy are discussed.

Intraventricular meningiomas: A surgical challenge

Background Primary intraventricular meningiomas (IVM) pose a surgical challenge as they often remain asymptomatic until they become very large; have close proximity to vital intraventricular structures; and, their vascular supply is often encountered only after significant tumor debulking. In this study, the surgical management of IVM is discussed. Methods Between 1989 and 2003, nine patients (7 with lateral and 2 with fourth ventricular) IVM, were operated upon. Raised intracranial pressure, gait ataxia, memory impairment, seizures (motor and sensory) were the main presentations. Four had hydrocephalus while five had either a sequestered temporal or occipital horn. All were large tumors with an average size more than 5.3 cm. The lateral ventricular IVM were accessed by the posterior middle temporal gyrus ( n = 5) or the superior parietal lobule ( n = 2) approach. A midline suboccipital craniectomy was used for the fourth ventricular IVM. Results Total excision was achieved in eight and partial excision in one. Patients with lateral ventricular tumors required a postoperative intraventricular drain for a minimum period of 48 hours. The main morbidity included visual field defects and transient hemiparesis, seizure and meningitis. The one patient with partial excision died 6 weeks later due to transtentorial herniation as a result of intratumoral bleed and lateral ventricular sequestration. Conclusions An IVM, being initially asymptomatic, usually attains a large size before detection. During surgery, its devascularisation is usually achieved only after significant tumor debulking. Development of hydrocephalus or ventricular sequestration should be constantly monitored and may be avoided in the postoperative period by continuous external ventricular drainage.

Subdural Haematoma in Patients With Spontaneous Intracranial Hypotension

The incidence and clinical relevance of subdural haematoma (SDH) in patients with spontaneous intracranial hypotension (SIH) remain undetermined. We reviewed 40 consecutive SIH patients (18 female, 22 male) in a tertiary hospital. Eight (20%) of them had SDH and nine (23%), non-haemorrhagic subdural collections. The presence of SDH was associated with higher frequencies of male gender, recurrence of severe headache and neurological deficits. Outcomes were satisfactory after supportive care or epidural blood patches except for one SDH patient, who developed transtentorial herniation resulting in Duret haemorrhage and infarctions of bilateral posterior cerebral artery territories. In conclusion, subdural fluid collections were common in patients with SIH. SDH was associated with headache worsening or neurological deficits. Patients with SDH generally recovered well; however, serious sequela might occur.

上行性テント切痕ヘルニアをきたした椎骨動脈解離性動脈瘤破裂の2症例

上行性テント切痕ヘルニアをきたした椎骨動脈解離性動脈瘤破裂の2症例

Outcomes after decompressive craniectomy for severe traumatic brain injury in children

Severe traumatic brain injury (TBI) is often accompanied by early death due to transtentorial herniation. Decompressive craniectomy, performed alone or in conjunction with evacuation of the mass lesion, can reduce the incidence of raised intracranial pressure (ICP). In this paper the authors evaluate mortality and morbidity and long-term outcomes in children who underwent decompressive craniectomy for severe TBI at a single institution. Children with severe TBI who underwent decompressive craniectomy at the Primary Children's Medical Center between 1996 and 2005 were identified retrospectively. Descriptive statistics were used to report postoperative mortality and morbidity rates. Long-term recovery in patients who survived was reported using the King's Outcome Scale for Closed Head Injury (KOSCHI). Fifty-one children with a mean follow-up period of 18.6 months were identified. Nonaccidental trauma accounted for 23.5% of cases. The mean preoperative Glasgow Coma Scale (GCS) score was 4.6. Six patients underwent decompressive craniectomy for elevated ICP only; all other patients underwent decompressive craniectomy in conjunction with removal of the mass lesion. The mean postoperative GCS score was 9.7, and 69.4% of patients had normal ICP levels immediately after surgery. Sixteen children (31.4%) died, including five of six children who underwent decompressive craniectomy for raised ICP alone. Among surviving patients, 2.9% required a tracheostomy, 11.4% required a gastrostomy, 40% experienced posttraumatic shunt-dependent hydrocephalus, and 20% suffered posttraumatic epilepsy requiring antiepileptic agents. The mean KOSCHI score at the last follow-up examination was 4.5 and the mean time to cranioplasty was 2.3 months. Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high.

“Paradoxical” transtentorial herniation due to CSF drainage in the presence of a hemicraniectomy

Decompressive hemicraniectomy can be a life-saving treatment for uncontrolled elevations in intracranial pressure (ICP) due to trauma or space-occupying ischemic or hemorrhagic stroke.1 Herniation in the direction opposite the site of the craniectomy—paradoxical herniation—is an underrecognized and potentially fatal complication of this procedure. It can occur spontaneously or may be precipitated by a lumbar puncture (LP) or a CSF shunt. It is critical to recognize this treatable entity because standard interventions aimed at lowering ICP are harmful. A 24-year-old man with a right-sided subdural hemorrhage (SDH) and temporal contusion from head trauma underwent SDH evacuation, anterior temporal lobectomy, and a right-sided hemicraniectomy. Subsequently, a medium pressure ventriculoperitoneal shunt (VPS) was placed for hydrocephalus. Two months later, he followed simple commands and had a left-sided hemianopsia and hemiparesis. At this time, his scalp was slightly sunken over the skull defect. He was transferred to our hospital for rehabilitation, where he developed fevers and decreased responsiveness. An LP revealed an opening pressure of 11 cm H2O. …

Unilateral mydriasis from ipratropium in transplant patients

Intracranial hemorrhage (ICH) is common in autopsy series of hematopoietic cell transplantation (HCT).1 ICH often presents with third nerve signs of transtentorial herniation. Unilateral pupillary dilatation from scopolamine, used as a transdermal patch for post-HCT nausea, can be a false indicator of ICH.2 I describe similar diagnostic confusion with ipratropium/albuterol (I/A) in four patients with HCT. I studied four men, aged 22 to 64 years (median 41 years), who had undergone allogeneic HCT 1 to 6 months previously (table). All patients had multiple complications after transplant, including two patients with alveolar hemorrhage, atrial fibrillation, and renal failure requiring dialysis. Patient 1 had enterococcal meningitis, and Patient 4 had aspergillus pulmonary infection. All four patients had recent bacteremia, and all were thrombocytopenic with platelet counts of 27,000 to 94,000/μL (median 46,000/μL) on the day of the neurologic consultation. View this table: Table Transplant …

Decompressive hemicraniectomy for tumefactive demyelination with transtentorial herniation: observation

Decompressive hemicraniectomy for tumefactive demyelination with transtentorial herniation: observation

High Intracranial Pressure, Brain Herniation and Death in Cerebral Venous Thrombosis

To the Editor: Sir, the study by Canhao and colleagues made the important point that the most frequent cause of death in patients with cerebral venous thrombosis (CVT) is transtentorial herniation and that these patients may potentially have benefited from decompressive hemicraniectomy.1 We would like to corroborate this argument by providing evidence for a rise in intracranial pressure (ICP) preceding brain herniation and death in a patient with CVT. A 29-year-old pregnant woman who presented with confusion and vomiting was admitted to a district general hospital. A right-sided weakness developed within 2 days. A CT brain scan showed a left temporal hemorrhage without mass effect. Her Glasgow Coma Scale score dropped to 8/15; she was intubated and transferred to the neurocritical care …

Community-Acquired Bacterial Meningitis in Adults

This review summarizes recent changes in the treatment of adults with community-acquired bacterial meningitis. It explains the initial assessment and management, the use of adjunctive corticosteroids, and intensive care monitoring. The authors detail the approach to complications such as transtentorial herniation, hydrocephalus, and focal seizures.

Cerebral hemodynamic changes gauged by transcranial Doppler ultrasonography in patients with posttraumatic brain swelling treated by surgical decompression

The use of decompressive craniectomy has experienced a revival in the previous decade, although its actual benefit on patients' neurological outcome remains the subject of debate. A better understanding of the intracranial pressure dynamics, as well as of the metabolic and hemodynamic brain processes, may be useful in assessing the effect of this surgery on the pathophysiology of the swollen brain. The aim of this study was to use transcranial Doppler (TCD) ultrasonography to examine the hemodynamic changes in the brain after decompressive craniectomy in patients with head injury, in addition to examining the relationship between such hemodynamic changes and the patient's neurological outcome. Nineteen patients presenting with traumatic brain swelling and cerebral herniation syndrome who had undergone decompressive craniectomy with dural expansion were studied prospectively. The TCD ultrasonography measurements were performed bilaterally in both the middle cerebral artery (MCA) and in the distal portion of the cervical internal carotid artery (ICA) immediately prior to and after surgical decompression. After surgery, the mean blood flow velocity (BFV) rose to 175 +/- 209% of preoperative values in the MCA of the operated side, while rising to 132 +/- 183% in the contralateral side; the difference between the mean BFV increase in in the MCA of both the decompressed and the opposite side reached statistical significance (p < 0.05). The mean BFV of the extracranial ICA increased to 91 +/- 119% in the surgical side and 45 +/- 60% in the opposite side. Conversely, the MCA pulsatility index (PI) values decreased, on average, to 33 +/- 36% of the preoperative value in the operated side and to 30 +/- 34% on the opposite side; the MCA PI value reductions were significantly greater in the decompressed side when compared with the contralateral side (p < 0.05). The PI of the extracranial ICA reduced, on average, to 37 +/- 23% of the initial values in the operated side and to 24 +/- 34%, contralaterally. No correlation was verified between the neurological outcome and cerebral hemodynamic changes seen on TCD ultrasonography. Decompressive craniectomy results in a significant elevation of cerebral BFV in most patients with traumatic brain swelling and transtentorial herniation syndrome. The increase in cerebral BFV may also occur in the side opposite the decompressed hemisphere; the cerebral BFV increase is significantly greater in the operated hemisphere than contralaterally. Concomitantly, PI values decrease significantly postoperatively, mainly in the decompressed cerebral hemisphere, indicating reduction in cerebrovascular resistance.

Craniectomy for middle cerebral artery infarction

Malignant middle cerebral artery (MCA) infarction is defined as rapid clinical deterioration and poor outcome as a result of increased intracranial pressure and transtentorial herniation, occuring in 10–15% of supratentorial infarctions and with a mortality rate of up to 80%. The case report by St George et al (p. 702) published in this issue of the British Journal of Hospital Medicine aims to increase the awareness of this clinical condition among physicians managing patients with ischaemic stroke and discusses the implications of an early vs late referral to the local neurosurgical unit.

Decorticate, decerebrate and opisthotonic posturing and seizures in Kenyan children with cerebral malaria

BackgroundAbnormal motor posturing is often observed in children with cerebral malaria, but the aetiology and pathogenesis is poorly understood. This study examined the risk factors and outcome of posturing in Kenyan children with cerebral malaria.MethodsRecords of children admitted to Kilifi district hospital with cerebral malaria from January, 1999 through December, 2001 were reviewed for posturing occurring on or after admission. The clinical characteristics, features of raised intracranial pressure, number of seizures and biochemical changes in patients that developed posturing was compared to patients who did not.ResultsOf the 417 children with complete records, 163 (39.1%) had posturing: 85 on admission and 78 after admission to hospital. Decorticate posturing occurred in 80, decerebrate in 61 and opisthotonic posturing in 22 patients. Posturing was associated with age ≥ 3 years (48.1 vs 35.8%, p = 0.01) and features of raised intracranial pressure on funduscopy (adjusted OR 2.1 95%CI 1.2–3.7, p = 0.009) but not other markers of severity of disease. Unlike decorticate posturing, decerebrate (adjusted OR 1.9 95%CI 1.0–3.5) and opisthotonic posturing (adjusted OR 2.9 95%CI 1.0–8.1) were, in addition, independently associated with recurrence of seizures after admission. Opisthotonus was also associated with severe metabolic acidosis (OR 4.2 95%CI 3.2–5.6, p < 0.001). Thirty one patients with posturing died. Of these, 19 (61.3%) had features suggestive of transtentorial herniation. Mortality and neurological deficits on discharge were greatest in those developing posturing after admission.ConclusionAbnormal motor posturing is a common feature of cerebral malaria in children. It is associated with features of raised intracranial pressure and recurrence of seizures, although intracranial hypertension may be the primary cause.

Duret hemorrhage is not always suggestive of poor prognosis: a case of acute severe hyponatremia

A 30-year-old man who had been admitted to a mental hospital with a diagnosis of schizophrenia was found having clonic seizures early in the morning and was admitted to the ED in a deep comatose state. Polydipsia had been observed for several days. On arrival, the Glasgow Coma Scale of the patient was 3/15 with fully dilated and nonreactive pupils. Laboratory examination showed severe serum electrolyte abnormalities: sodium concentration of 103 mEq/L, chloride concentration of 70 mEq/L, and an osmolality of 216 mosm/kg. Computed tomography (CT) of the brain showed severe diffuse cerebral edema and obliteration of the cisterns (Fig. 1). Acute severe hyponatremia resulting in serious brain swelling causing descending transtentorial herniation was diagnosed. Rapid correction of the serum sodium concentration was immediately initiated by the infusion of

Paradoxical Cerebral Herniation Secondary to Lumbar Puncture after Decompressive Craniectomy for a Large Space-occupying Hemispheric Stroke: Case Report

The risk of transtentorial herniation after removal of cerebrospinal fluid from the lumbar cistern in the setting of a supratentorial lesion with significant mass effect, increased cerebrospinal fluid pressure, or midline shift is well known. We report a case of cerebral herniation from intracranial hypotension (so-called paradoxical herniation) secondary to a lumbar puncture 1 month after decompressive hemicraniectomy for a large right hemispheric stroke. A 50-year-old woman was transferred to our neurosurgical service for obtundation 4 days after a lumbar puncture to rule out meningitis and 1 month after decompressive craniectomy for a large right hemispheric stroke. Eighty grams of mannitol was administered before transfer. On arrival at our hospital, the patient was intubated and a computed tomographic scan was performed. The patient was diagnosed with low-pressure herniation after review of the computed tomographic scan. Rehydration was initiated, and the patient was placed in the Trendelenburg position. She became easier to arouse, but her pupils remained dilated. She experienced a sudden severe cardiac arrhythmia leading to a cardiac arrest. Attempted resuscitation was unsuccessful, and the patient was pronounced dead. Lumbar punctures may result in lethal intracranial hypotension in patients after hemicraniectomy and are thus contraindicated unless care is taken to remove the pressure gradient of atmospheric air across the lumbar cistern.

Herniation Secondary to Critical Postcraniotomy Cerebrospinal Fluid Hypovolemia

Cerebrospinal fluid hypovolemia resulting in postural headaches is a well-known clinical entity, but severe forms of cerebrospinal fluid hypovolemia with altered mental status and signs of transtentorial herniation ("brain sag") have rarely been reported. This article describes the clinical features of brain sag after craniotomy in an attempt to increase recognition of this syndrome. Between April 2001 and January 2003, 220 consecutive patients with subarachnoid hemorrhage were prospectively enrolled in the Columbia Subarachnoid Hemorrhage Outcomes Project; 137 underwent craniotomy for aneurysm clipping. Among these patients, the diagnosis of brain sag was made when all three of the following criteria were present: clinical signs of transtentorial herniation, head computed tomographic scans revealing effacement of the basal cisterns with an oblong brainstem, and improvement of symptoms after placement of the patient in the Trendelenburg position (-15 to -30 degrees). For each patient, the symptoms, clinical course, and subsequent response to treatment were characterized. In addition, brainstem dimensions were measured on computed tomographic scans taken before, during, and after resolution of brain sag. A "sag ratio" was generated for these time points by dividing the maximum anteroposterior distance by the maximum bipeduncular distance. Eleven (8.0%) of 137 aneurysmal subarachnoid hemorrhage patients treated by craniotomy and an intraoperative spinal drain met the criteria for brain sag. Signs of transtentorial herniation developed most commonly between 2 and 4 days postoperatively. Pupillary asymmetry was noted in 10 (91.0%) of 11 patients, whereas the other patient demonstrated extensor posturing. The Trendelenburg position reversed the symptoms in all patients. The mean sag ratios before, during, and after resolution of brain sag were 0.91 +/- 0.03 (mean +/- standard error), 1.18 +/- 0.03, and 0.91 +/- 0.03, respectively. This represented a 30.9% elongation of the brainstem during sag (P < 0.001) and a 23.6% change back to baseline after resolution of the syndrome (P < 0.002). There was no significant difference between the presag and postsag ratios. Severe cerebrospinal fluid hypovolemia after craniotomy may produce a dramatic herniation syndrome that is completely reversed by the Trendelenburg position. Brain sag should be included in the differential diagnosis for acute postoperative clinical deterioration in this patient population.

The relationship between clinical signs and brain herniation associated with rostrotentorial mass lesions in the dog

Retrospective analysis of magnetic resonance imaging and clinical findings in a referral population of dogs was used to determine the relationship between rostrotentorial space-occupying lesions and the development of secondary neurological signs. Brain herniation was detected in 54/153 cases of uni-focal rostrotentorial space-occupying lesions; of these 30 had caudal transtentorial herniation (CTH) and 24 had both transtentorial and foramen magnum herniation (CTH/FMH). Masses associated with herniation were larger and situated more dorsally and caudally within the cranial vault. Clinical signs classically associated with CTH, e.g., oculomotor nerve palsy, were seen in only one case of isolated CTH and seven (14%) of all herniation cases. Deficits in caudal cranial nerve function were detectable in 39% of cases with FMH. We conclude that severe shifts in brain parenchyma can exist in the absence of detectable localising signs.

Causes and Predictors of Death in Cerebral Venous Thrombosis

The causes of death of patients with cerebral venous thrombosis (CVT) have not been systematically addressed in previous studies. We aimed to analyze the causes and predictors of death during the acute phase of CVT in the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) to identify preventable or treatable causes. ISCVT is a multinational, prospective, observational study including 624 patients with CVT occurring between May 1998 and May 2001, in which 27 patients (4.3%) died during the acute phase, 21 (3.4%) within 30 days from symptom onset. Inclusion forms and a questionnaire assessing the causes of death were analyzed. A logistic regression analysis was performed to identify the predictors of death within 30 days from symptom onset of CVT. Median time between onset of symptoms and death was 13 days and between diagnosis and death, 5 days. Causes of death were mainly transtentorial herniation due to a unilateral focal mass effect (10 patients) or to diffuse edema and multiple parenchymal lesions (10 patients). Independent predictors of death were coma (odds ratio [OR], 8.8; 95% confidence interval [CI], 2.8 to 27.7), mental disturbance (OR, 2.5; 95% CI 0.9 to 7.3), deep CVT thrombosis (OR, 8.5; 95% CI, 2.6 to 27.8), right intracerebral hemorrhage (OR, 3.4; 95% CI, 1.1 to 10.6), and posterior fossa lesion (OR, 6.5; 95% CI, 1.3 to 31.7). Worsening of previous focal or de novo focal deficits increased the risk of death. The main causes of acute death were neurologic, the most frequent mechanism being transtentorial herniation.

Upward Transtentorial Herniation, Hydrocephalus, and Cerebellar Edema in Hypertensive Encephalopathy

Edema of the cerebellum with secondary obstructive hydrocephalus is a rare presentation of hypertensive encephalopathy. The authors report an unusual case of isolated posterior fossa swelling with upward transtentorial herniation and hydrocephalus causing neurologic deterioration. These patients are often initially evaluated by a neurologist because of the acute neurologic symptoms. Prompt diagnosis with aggressive blood pressure control may obviate the need for emergent cerebrospinal fluid (CSF) diversion. This is a case report of a 26-year-old man who presented to the emergency room with confusion and somnolence over a 2-day period. His initial blood pressure was 175/110 mmHg. On examination he was disoriented, with a Glasgow Coma Scale score of 12 points, opening his eyes only to loud verbal stimuli, verbalizing inappropriately, and he was only able to follow simple commands. Neuroimaging revealed edema of the cerebellar folia with noncommunicating hydrocephalus and upward transtentorial herniation. Differential diagnoses of posterior fossa tumor, rhombencephalitis, and hypertensive encephalopathy were entertained. A thorough literature review is included with the discussion of this case. The patient underwent emergent ventriculostomy for CSF drainage and prompt blood pressure control with nitroprusside. After 48 hours of CSF drainage and correction of his hypertension, his neurologic examination normalized. Repeat imaging revealed near resolution of the obstructive hydrocephalus and cerebellar edema. Isolated edema of the cerebellum with upward transtentorial herniation and obstructive hydrocephalus is a rare presentation of hypertensive encephalopathy and should be considered in patients with an acute hypertensive crisis and mental status changes. This entity responds to prompt blood pressure control; however, emergent ventriculostomy by a neurosurgical team should be entertained for neurologic deterioration secondary to significant obstructive hydrocephalus, as illustrated in this case.

Potentiels évoqués et évolution post-traumatique

Visual, somatosensory, and brainstem auditory evoked potentials provide functional quantitative assessment of the cerebral cortex and brainstem. Their contribution at the acute stage of coma concerns diagnosis, prognosis, and follow-up. Four patterns are observed in traumatic coma: pattern 1 = dysfunction of the cerebral cortex, brainstem integrity: good prognosis in more than 80% of cases; pattern 2 = midbrain dysfunction: prognosis depends on both the reversibility of midbrain dysfunction and the extent of associated axonal lesions in the hemispheric white matter; pattern 3 = pontine dysfunction due to transtentorial herniation: ominous prognosis, this pattern must be early detected by continuous monitoring; pattern 4 = brain death: we currently use evoked potentials at the only brain-death confirmatory test, even in sedated patients. The contribution of evoked potentials in vegetative or minimally responsive states concerns the identification of these patients whose state is determined by midbrain dysfunction and the evaluation of persisting cognitive abilities in individual cases.