Brain Herniation Syndrome

Herniation Syndrome

Dr Sarah ‘Atiqah Mohd Zamri Medical Ofcer Neurosurgery Neurosurgery Department

Outline •

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Anatomy o cisterns  most common herniation •

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Supratentorial! Supratentorial! inratentorial inratentorial Mechanism "maging #linical maniestation maniestation

Summary stages o herniation $reathing pattern %eerences

"ncisular cistern "nterpedunc ular cistern Am'ient cistern

(uadrigemina l cistern

*entagon o 'asal cistern +suprasellar cistern, *ontine cistern

*ontocere'ell ar cistern

5 most common herniation syndrome Supratentorial 1. &. ). -. .

herniation #ingulate herniation / a.0.a. su'alcine herniation #entral +transtentorial, herniation ncal herniation 2onsillar herniation "nratentorial herniation p3ard cere'ellar

Central herniation (a.k.a transtentorial a.k.a tentorial herniation) sually more chronic than uncal herniation •

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4.g. tumor / rontal! parietal or occipital lo'es Diencephalon orced through tentorial incisura *ituitary stal0 may 'e sheared  dia'etes insipidus *#As may 'e trapped along the open edge o the incisura / may occlude  cortical 'lindness $rainstem ischemia rom compression and shearing perorating arteries rom 'asilar artery  haemorrhage 3ithin 'rainstem  Duret Hemorrhage

Central herniation •

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Mechanism : do3n3ard displacement o cere'ral hemisphere and the 'asal nuclei compressing and displacing the diencephalon and the mid'rain rostrocaudally through the tentorial notch Imaging fndings : • • •

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46acement o sulci O'literation o suprasellar cistern #ompression and posterior displacement o quadrigeminal cistern

Clinical maniestations: • • • •

Medium si7ed! 89ed pupils Somnolence! 4arly coma Decorticate posturing #heyne sto0es respiration •

a cyclical crescendo:decrescendo pattern o 'reathing! ollo3ed 'y periods o central apnea

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Duret hemmorhage

Uncal herniation

Uncal herniation •

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Mechanism : %apidly e9panding hematoma at middle:ossa or temporal lo'e pushing medial uncus and hippocampal gyrus o?er edge o tentorium! entrapping ) rd ner?e and directly compressing mid'rain Imaging: • • • •

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#ontralateral temporal horn 3idening "psilateral am'ient cistern 3idening "psilateral prepontine cistern 3idening ncus e9tending into suprasellar cistern

Clinical Maniestation • • •

4arliest sign @ ipsilateral pupil dilatationanisocoria Opthalmoplegia #ontralateral hemiparesis •

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#ontralateral cere'ral peduncle may 'e compressed against the tentorial edge causing ipsilateral hemiplegia +BernohanCs phenomenon! alse locali7ing sign,

Somnolence Decere'rate posturing

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Right hemispheric chronic SDH with gross midline shift and eacement of perimesencephalic cistern, subfalcine and transtentorial herniation. P ostoperative axial CT head showing left PCA territory infarct.

Bernohan notch : made 'y tentorial edge on cere'ral peduncle contralateral to side o hemispheric mass lesion. BernohanEs notch phenomenon is the ipsilateral hemiplegia caused 'y compression o the contralateral cere'ral peduncle against the tentorial edge 'y a supratentorial mass

ncal herniation •

$ilateral uncal herniation / suprasellar cistern o'literated

Sualcine herniation aka cingulate herniation

Sualcine herniation •

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Mechanism : 'rain tissue e9tending under the al9 in supratentorial cere'rum Imaging : • • • •

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Attenuation o ipsilateral aspect o rontal horn Asymmetric anterior al9 O'literation o ipsilateral atrium o lateral ?entricle Septum pellucidum shit

Clinical maniestation • • • •

Small reacti?e pupils Headache Somnolence #ontralateral leg paralysis

!onsillar herniation •

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Mechanism : a mass e6ect in the posterior ossa causing the cere'ellar tonsils herniatingprotruding 'elo3 the oramen magnum compressing the medulla and upper cer?ical cord Imaging : •

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#ere'ellar tonsils at le?el o dens on a9ial images #ere'ellar tonsils on sagittal images mm 'elo3 oramen magnum +;mm in children,

Clinical maniestation •

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Hypertension:'radycardia:'radypnea #oma %espiratory arrest #ardiac arrhytmia $ilateral arm dyesthesia

!onsillar herniation

U"#ard cereellar herniation •

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Mechanism : inratentorial mass e6ect protruding up3ard compressing the mid'rain Imaging : •

Spinning top appearance o mid'rain •

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due to com"ression ilaterally on the "osterolateral as"ects o the midrain as the "osterior ossa s$uee%es through the incisura rom elo#

Narro3ing o 'ilateral am'ient cisterns Filling o quadrigeminal cisternsCcroo0ed smileC Hydrocephalus i aqueduct o syl?ius compressed

Clinical maniestation @ •

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Nausea?omiting *rogressi?e stupor

 

Consciousn ess

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*ience"ha Altered lic stage alertness Gethargy Agitation Gater@ stupor : coma

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Midrain , u""er "ons stage

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-o#er "ons , u""er medullary stage Medullary stage (terminal stage)

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arly / rd ner0e stage

'es"irations Sighs  Ia3ns Gater @ #heyne : Sto0es

#heyne / Sto0es

u"ils

Oculomotor

Motor

Small +1:)mm,! small range o contraction

#onJugate or slightly di?ergent ro?ing eyesK i conJugate the 'rainstem intact. sually positi?e DollCs eyes and conJugate ipsilateral response to #old Later #alorics +#L#,. "mpaired upga7e due to compression o superior colliculi and diencephalic pretectum +*arinaudCs syndrome, DollCs eyes  #L# impaired! may 'e dysconJugate. MGF lesion  internuclear opthalmoplegia +3hen dollCs or #L# elicited and dysconJugate! medially mo?ing eye mo?es less than laterally mo?ing eye. DollCs eyes and #L# unelicita'le

4arly@ appropriate response to no9ious stimuli! 'ilateral $a'ins0i! gegenhelten +para tonic resistance,. " pre?iously hemiparetic! may 3orsen. Gater @ motionlessness  grasp ree9es! then Decorticate +initially contralateral to lesion,

):mm! 89ed

 sustained

tachypnea

%egular! shallo3 and rapid +&>: ->min,

):mm 89ed

Slo3! irregular rate and depth! sighsgasps. Hyperpnea alternate 3ith apnea. Normal

Dilated 3idely 3ith hypo9ia

nilaterally dilatedsluggish pupilK