What are the 4 types of supratentorial herniation?

-- Subfalcine (cingulate) herniation -- Uncal herniation (transtentorial herniation) -- Central herniation -- Transcalvarial herniation (through the calvarium)

What happens in a Subfalcine (cingulate) herniation?

Cingulate gyrus on one side is pushed underneath the falx cerebri.

Where is the cingulate gyrus?

What are the clinical symptoms of a Subfalcine (cingulate) herniation?

-- usually none unless the Anterior Cerebral Arteries are compromised. -- These arteries supply the leg and foot of the precentral (motor) and postcentral (sensory) gyrus.

What areas are supplied by the anterior cerebral arteries: Blue in picture.

Define uncal herniation:

--Herniation of the medial temporal lobe inferiorly through the tentorial notch.

What is the clinical triad associated with uncal (transtentorial) herniation?

-- blown pupil -- hemiplegia (paralysis of half the body) -- coma

Why do we see blown pupil with uncal herniation?

Because the occulomotor nerve comes off the brain very close to there and is compressed by the herniated area. The parasympathetic fibers are located in the nerve external to the motor fibers --> therefore the blown pupil is seen first . . . later there may be motor deficits to the muscles supplied by III. -- blown pupil happens in 85% of cases

Why do we see hemiplegia (paralysis of half the body) with uncal herniation?
Because the motor axons in the cerebral peduncles are compressed: -- compressed isilateral to herniation: hemiplegia will be on the contralateral side of the body (axons decussate at pyramidal decussation) -- compressed contralateral to herniation: If the herniation is very severe, the contralateral cerebral peduncle may be compressed by the opposite side of the tentorial notch leading to an ipsilateral (to the herniation) hemiplegia (Kernohan's phenomenon).

Why do we see coma with uncal herniation?

pressure on the midbrain reticular formation: It acts in: -- Somatic motor control -- Cardiovascular control -- Sleep and consciousness -- Habituation

describe Central herniation:

-- central downward pressure --> displacement of brain stem

name some diseases can cause central herniation?

-- hydrocephalus -- tumor -- cerebral edema

How may a central herniation manifest?

-- unilateral or bilateral VI nerve palsy (pressure on nerve as it passes over the clivus) (mild cases) -- uncal herniation (severe cases) -- tonsillar herniation (downward cerebellar herniation) (very severe cases) -- stretch or tearing of small branches of the basilar artery --> this can be fatal.

Describe transcalvarial herniation:

-- can be due to trauma or a deliberate surgical opening of the skull to alleviate pressure or cerebral edema of the brain.

What are the two types of infratentorial herniation?

-- tonsillar herniation (downward cerebellar herniation) -- upward cerebellar herniation

Describe tonsillar herniation:

Herniation of the cerebellar tonsils through the foramen magnum.

What are the clinical signs of tonsillar herniation?

-- respiratory arrest --> compression of some resp centers in the medulla. -- blood pressure instability -- death

Describe upward cerebellar herniation:

Usually caused by an expanding mass (tumor, blood) in the posterior fossa. The mass forces the medial cerebellum upward through the tentorial notch and compresses the midbrain.