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Updated: Dec 11 2021

Brain Herniation Syndromes

  • Snapshot
    • A 70-year-old man presents to the emergency department with confusion after having a convulsive episode. Prior to having a seizure, the patient reported to having a progressively worsening headache that awoke him from sleep, and right-sided weakness over the course of 7 months. On physical exam, there is weakness 2/5 strength throughout the right-side, and a left pupil that is unresponsive to light. A computerized tomography (CT) scan of the head shows a ring-enhancing lesion with surrounding cerebral edema. (Uncal herniation)
  • Introduction
    • Clinical definition
      • brain tissue herniation that can result in compression of
        • brain tissue
        • 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
      • Mechanism
      • Clinical Findings
      • Transtentorial herniation
      • The medial temporal lobe (especially, the uncus) herniates
        • through the tentorial 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
      • The brainstem becomes downwardly and centrally displaced
      • Unilateral or bilateral lacteral rectus palsy in 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
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