BRAIN HERNIATION SYNDROME
A Pictorial Review
Thorsang Chayovan R1/Aj.Nuttha
22.11.2014
BRAIN HERNIATION
most common types
Subfalcine herniation
descending transtentorial herniation
Others
Posterior fossa herniations
ascending transtentorial herniation
tonsillar herniation
Transalar herniation
Rare but important types
transdural/transcranial herniations
brain displacements across the sphenoid wing
SUBFALCINE HERNIATION
Subfalcine herniation
most common
supratentorial mass in one hemicranium
affected hemisphere pushes across the
midline under the inferior "free" margin of the
falx, extending into the contralateral
hemicranium
Subfalcine herniation: imaging
Axial and coronal images show that
cingulate gyrus
anterior cerebral artery (ACA)
internal cerebral vein (ICV)
are pushed from one side to the other under the
falx cerebri.
The ipsilateral ventricle appears compressed
and displaced across the midline
Complications
unilateral obstructive hydrocephalus
foramen of Monro occlusion
Periventricular hypodensity with "blurred"
margins of the lateral ventricle
Fluid accumulates in the periventricular white
matter
Complications
When severe, the herniating ACA can be
pinned against the inferior "free" margin of
the falx cerebri
secondary infarction of the cingulate gyrus
TRANSTENTORIAL HERNIATION
Transtentorial herniations
descending herniations
ascending herniations
Descending transtentorial herniations
the second most common
a hemispheric mass
initially produces subfalcine herniation
As the mass effect increases,
the uncus of the temporal lobe is pushed medially
begins to encroach on the suprasellar cistern
hippocampus follows
hippocampus effaces the ipsilateral quadrigeminal
cistern
both the uncus and hippocampus herniate inferiorly
through the tentorial incisura
"Dysautonomia, Multisystem Atrophy and Parkinson's." Dysautonomia, Multisystem Atrophy
and Parkinson's. N.p., n.d. Web. 18 Nov. 2014
Descending transtentorial herniation
Unilateral
Bilateral ("central)
Severe
unilateral DTH: imaging
early
uncus is displaced medially
Ipsilateral aspect of the suprasellar cistern
effaced
Ipsilateral prepontine + cerebellopontine angle
cistern enlarged
Descending transtentorial herniation
As DTH increases
hippocampus also herniates medially
quadrigeminal cistern compression
midbrain pushed toward the opposite side of
the incisura
Descending transtentorial herniation
severe cases
entire suprasellar and quadrigeminal cisterns
are effaced.
The temporal horn can even be displaced almost
into the midline
bilateral DTH
both hemispheres become swollen
the whole central brain is flattened against the
skull base
All the basal cisterns are obliterated
hypothalamus and optic chiasm are crushed
against the sella turcica
Complete bilateral DTH
both temporal lobes herniate medially into the
tentorial hiatus
midbrain and pons displaced inferiorly through
the tentorial incisura
The angle between the midbrain and pons
is progressively reduced from 90 to almost 0
Complications
CN III (oculomotor) nerve compression
CN III palsy
PCA occlusion as it passes back up over the
medial edge of the tentorium
secondary PCA (occipital) infarct
Kernohan notch
As the herniating temporal lobe pushes the
midbrain toward the opposite side of the
incisura
contralateral cerebral peduncle is forced against
the hard edge of the tentorium
Pressure ischemia ipsilateral hemiplegia
the "false localizing" sign
Duret hemorrhage
"Top-down" mass effect displaces the midbrain
inferiorly
closes the midbrain-pontine angle
Perforating arteries from basilar artery
are compressed and buckled
secondary hemorrhagic midbrain infarct
Brainstem hemorrhage
Brainstem hemorrhage
Dorsolateral
Primary
injury
Severe DAI
Ventral
paramedian
Duret
Hemorrhage in diffuse axonal injury
Gray-white junction
Corpus callosum
Brainstem
hypothalamic and basal ganglia
infarcts
complete bilateral DTH
perforating arteries from the circle of Willis
compression against the central skull base
hypothalamic and basal ganglia infarcts
POSTERIOR FOSSA MASS:
TONSILLAR HERNIATION
ASCENDING TRANSTENTORIAL HERNIATION
Tonsillar herniation
The cerebellar tonsils are displaced inferiorly and
become impacted into the foramen magnum.
congenital (e.g., Chiari 1 malformation)
mismatch between size and content of the posterior
fossa
Acquired
an expanding posterior fossa mass pushing the tonsils
downwardmore common
intracranial hypotension: abnormally low intraspinal
CSF pressure
tonsils are pulled downward
Tonsillar herniation: imaging
Diagnosing tonsillar herniation on NECT scans
may be problematic.
Cisterna magna obliteration
Tonsillar herniation: imaging
MR: much more easily diagnosed
In the sagittal plane
the tonsillar folia become vertically oriented
the inferior aspect of the tonsils becomes pointed
Tonsils > 5 mm (or 7 mm in children) below the
foramen magnum are generally abnormal
especially if they are peg-like or pointed (rather than
rounded)
Tonsillar herniation: imaging
In the axial plane, T2 scans show that the
tonsils are impacted into the foramen
magnum
obliterating CSF in the cisterna magna
displacing the medulla anteriorly
Complications
obstructive hydrocephalus
tonsillar necrosis
ASCENDING TRANSTENTORIAL
HERNIATION
Ascending transtentorial herniation
caused by any expanding posterior fossa mass
Neoplasms > trauma
Complications
Acute intraventricular obstructive
hydrocephalus
caused by compression of the cerebral aqueduct
OTHER LESS COMMON HERNIATION:
TRANSALAR
TRANSDURAL/TRANSCRANIAL
HERNIATIONS
Transalar Herniation
brain herniates across the greater sphenoid
wing (GSW) or "ala"
ascending > descending
Ascending transalar herniation
caused by a large middle cranial fossa mass
An intratemporal or large extraaxial mass
Temporal lobe + sylvian fissure + MCA
up and over the greater sphenoid wing
Descending transalar herniation
caused by a large anterior cranial fossa mass
Gyrus rectus is forced posteroinferiorly over the
GSW
displacing the sylvian fissure and shifting the
MCA backward
Transdural/Transcranial Herniation
Rare
Sometimes called a "brain fungus"
can be life-threatening
Lacerated dura + a skull defect + increased ICP
Transdural/Transcranial Herniation
Traumatic
infants or young children with a comminuted
inward skull fracture
Iatrogenic
a burr hole, craniotomy, or craniectomy
Transdural/Transcranial Herniation
MR best depicts these unusual herniations.
The disrupted dura
discontinuous black line on T2WI
Brain tissue, blood vessels, and CSF, are extruded
through the defects into the subgaleal space
Kaewlai, R. Imaging of Traumatic Brain Injury. 2013.
Wikipedia
References
Osborn, Anne G. "Secondary Effects and
Sequellae of CNS Trauma."Osborn's Brain:
Imaging, Pathology, and Anatomy. Salt Lake City,
UT: Amirsys Pub., 2013. N. pag. Print.
Osborn, Anne G. "Cerebral Vasculature: Normal
Anatomy and Pathology."Diagnostic
Neuroradiology. St. Louis: Mosby, 1994. N. pag.
Print.
Kaewlai, R. Imaging of Traumatic Brain Injury.
2013. Web.
