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Nuero - Brain Herniation
Nuero - Brain Herniation
Everyon
Brain Herniation
Definition:
Cerebral tissues of temporal lobe
are squeezed to posterior cranial
fossa through tentorial incisure.
Transtentorial herniations occur
when the brain traverses across the
tentorium at the level of the incisura.
These can be divided into ascending
and descending transtentorial
herniations.The latter is common.So
we emphasis on discussing it.
Descending transtentorial
herniations are a larger
category caused by mass effect
in the cerebrum which pushes
the supratentorial brain tissue
through the incisura to the
posterior fossa.
Ascending transtentorial
herniation is caused by
mass effect in the posterior
fossa which leads to brain
extending through the
incisura in an upward.
Clinical Manifestation
1. Severe headache: caused by IIP.
2. Disturbance of consciousness,
drowsiness, especially coma,et al.
The reticular formation of midbrain
is involved.
3. Pupillary Alteration,from one
pupil dilated to bilateral pupils
dilated:Due to involvement of the
third cranial nerve.
4.Motor disturbance, hemiplegia,
decerebrate rigidity:pyramidal
tract of brain stem is involved.
5.Vital signs disorder: Cushing’s
response
All of them are very important and
must be kept in mind, because the
diagnosis is based on these clinical
findings.
These clinical situation may be isolated
or occur together. Ipsilateral pupil
dilatation occurs as the parasympathetic
fibers, which are located around the
outer aspect of the third nerve, are
compressed by the uncus. This leads to
dysfunction of the parasympathetic
fibers with subsequent unopposed
sympathetic responds. This will dilate
the ipsilateral pupil.
Contralateral hemiparesis
occurs with compression of the
ipsilateral cerebral peduncle.
Since the cortical spinal tracts
decussate (cross over) below
the mid brain in the level of
pons, the hemiparesis is
contralateral.
In some cases, an ipsilateral hemiparesis
can occur with a contralateral dilated
pupil or oculomotor paresis. This occurs
when the lateral translation of the
brainstem is so great as to push the
midbrain and cerebral peduncles all the
way across the perimesencephalic
cistern, so that the opposite
(contralateral) third nerve and cerebral
peduncle are pressed against the opposite
This phenomenon is called a
Kernohan’s notch - a hemorrhage
that occurs in the contralateral
cerebral peduncle (image shows
damage of the right peduncle with
hemorrhage centrally from
Durette hemorrhage).
Thus causing ipsilateral
hemiparesis. This neurologic sign
can be termed a "false localizer",
since it can be confusing or
misleading for lateralization of the
inciting lesion's location.
Imaging findings of descending
transtentorial herniations include
ipsilateral ambient cistern widening and
ipsilateral prepontine cistern widening.
A contralateral temporal horn is also
widened. These findings occur as the
ipsilateral, lateral ventricle is
compressed with subsequent dilatation
of the contralateral ventricle to
maintain the same volume.
ipsilateral ambient cistern widening
ipsilateral prepontine cistern widening
contralateral temporal horn is also widened
The ipsilateral
cistern is widened
because of the fact
that the brain
stem is inferiorly
contiguous with
the spinal cord
leading to a long
rigid structure as
shown in the
coronal CT image.
Note the mass on the right with
widening of the ipsilateral, right
ambient cistern. As the
supratentorial brain shifts to
the right, the superior aspect of
this long column of mid brain
and cord also shifts to the right.
This will
narrow the
contralateral
cistern and
widen the
ipsilateral
cistern at the
anterolateral
aspects of the
brain stem.
Uncal herniation is a subset of
descending transtentorial herniations.
The uncus is displaced into the
suprasellar cistern. The usual six
pointed star appearance of the
suprasellar cistern then becomes
truncated on the ipsilateral side of the
herniation. Coronal imaging can also
demonstrate uncal herniation either
by CT or MRI.
usual six pointed star appearance of the
suprasellar cistern
truncated on the ipsilateral side of the
herniation
This CT scan demonstrates a Durette
hemorrhage, descending transtentorial
shift to the left, widening of the
contralateral, right temporal horn and
a residual ipsilateral ambient cistern
(left) still remaining. The uncus is also
filling the left aspect of the suprasellar
cistern.
Complications of descending
transtentorial herniations include
occipital infarction. The posterior
cerebral artery becomes
compressed as the ipsilateral uncus
and parahippocampal gyrus
compresses the artery against the
ipsilateral cerebral peduncle.
The gross specimen associated with
the CT of occipital infarcts
demonstrates the excellent
correlation. This can occur
unilaterally or bilaterally depending
on the extent of injury and amount of
mass effect. Generally, an ipsilateral
occipital infarct will appear first
followed by contralateral infarction.
Another
complication of
descending
transtentorial
herniation includes
Durette
hemorrhage. This
is due to pontine
perforators which
are displaced
downward by mass
effect.
The basilar artery
sends these
perforators
posteriorly into the
pons. As the pons
shifts inferiorly,
these perforators
are stretch and can
cause hemorrhage
within the brain
stem or pons.
Sagittal and axial MRI demonstrates the
hemorrhage in the dorsal lateral pons.
Kernohan’s notch is another type of
hemorrhagic damage caused by
transtentorial herniation. This is due
to compression of the contralateral
cerebral peduncle against the
incisura. If this occurs, it leads to
ipsilateral hemiparesis since the
cortical spinal tracts become
damaged.
The gross specimen demonstrates
hemorrhage in the left central midbrain from
Durette hemorrhage and cortical damage
with some hemorrhage at the right cerebral
peduncle consistent with Kernohan’s notch.
There is also a left uncal herniation.
Foramen Magnum Herniation
Defination:
Cerebellar tonsil is squeezed to
cervical vertebral canal through
foramen magnum and compresses
the medulla oblongata and
cervical spinal cord.
Clinical Manifestation
A neurologic examination would show an
impaired level of consciousness.
Depending on the severity of the
herniation, one or several brainstem
reflexes and cranial nerve functions will
be impaired. The patient would show an
inability to breathe consistently, and
heart rhythms would be irregular.
❂1. Severe headache: