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Updated: Dec 30 2021

Brain Herniation Syndromes

Images herniation.jpg
  • Snapshot
    • A 67-year-old man is brought to the emergency department by his son due to abnormal behavior. The son reports that the patient appeared to be confused and had left-sided weakness. Approximately 5 days prior to presentation the patient fell and hit his head; however, he decided to not seek medical care. On physical examination, the left pupil is unresponsive to light and there is 2/5 left-sided weakness. A computerized tomography (CT) scan of the head is shown. (Uncal herniation with Kernohan's phenomenom)
  • Introduction
    • Clinical definition
      • brain tissue herniation that can result in
        • compression of brain tissue
        • compression of vascular supply
    • Pathogenesis
      • space occupying masses can result in mass effect (intracranial structure displacement) and they include
        • tumor
        • edema
        • hemorrhage
  • Herniation Syndromes
    • Three Clinically Important Brain Herniation Syndromes
      Herniation Syndrome
      Clinical Findings
      Transtentorial herniation
      • The medial temporal lobe (especially, theuncus) herniates
        • through thetentorial notch
      • Uncal herniation triad
        • ipsilateral unresponsive("blown")pupil
        • hemiplegia
          • typically contralateral; however,
            • if midbrain is compressed on the opposite side it can result in
              • ipsilateral hemiplegia(Kernohan's phenomenon)
        • decreased level of consciousness secondary to
          • compression of the midbrain reticular formation and can progress to
            • coma
      Central herniation
      • Thebrainstem becomes downwardly and centrally dispaced
      • Unilateral or bilateral lacteral rectus palsyin cases of
        • mild central herniation that compresses the
          • abducens nerve
      • Bilateral uncal herniation in cases of
        • significant central herniation
      • Tonsillar herniation
        • cerebellar tonsils herniates through the foramen magnum that can result in
          • compression of the midbrain that leads to
            • respiratory arrest
            • cardiovascular instability
            • death
      Subfalcine herniation
      • The cingulate gyrus (as well as other structures) herniates under the falx cerebri
      • At times this can lead to anterior cerebral artery compression under the falx cerebri resulting in
        • infarction
    • Prevention
      • reduce intracranial pressure
        • elevate head of bed
        • hypertonics (mannitol, hypertonic saline)
      • improve CNS perfusion
        • fluids
        • vasopressors
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