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Herniation of brain tissue from one compartment (separated by calvarial and /or dural boudaries) to another
Compartments
Supratentorial
Right Left
Infratentorial
Spinal
Intracranial compartments
Brain tissue in each compartment is contained by (relative) intracranial boundaries:
Falx cerebri Tentorium cerebelli Skull base (foramen magnum)
Intracranial compartments
Neurocranium Falx cerebri
Tentorium Cerebelli
Intracranial Compartments
For each compartment there are laws of Intracranial volume en pressure Each compartment abides these laws as good as possible
Intracranial volume
Intracranial volume is constant and described by Monro-Kelly Doctrine:
Vol. Intracranial = V. Brain + V. CSF + V. Blood
Intracranial components are (almost) noncompressible Increase in one volume leads to decrease in another
Intracranial Pressure
Normal intracranial pressure: 5-15 mmHg
http://www.trauma.org/archive/neuro/icp.html
Intracranial Pressure
Pressure components:
Cerebral Perfusion Pressure (CPP) Mean Arterial Pressure (MAP) Intracranial Pressure (ICP)
CPP = MAP - ICP To maintain CPP: If ICP increases, MAP must increase (autoregulation)
Intracranial Pressure
When MAP cannot increase:
Increased ICP decreases CPP Decreased CPP leads to tissue ischemia Tissue ischemia leads to edema Edema leads to increased ICP Further increased ICP leads to:
Tissue death
When compartmental volume increases and pressure increases, brain tissue moves from one compartment to another
Ischemia Infection
Types of herniation :
Subfalcine
Transtentorial
Descending Ascending
Subfalcine Herniation
Mass effect in cerebral hemisphere forces brain tissue under the falx to opposite side
Subfalcine Herniation:
Structures involved
Falx Cingulate Gyrus Pericallosal Artery Anterior Cerebral Artery Corpus Callosum
Subfalcine Herniation:
Imaging findings
Ipsilateral cingulate gyrus is pushed down and under midline falx Contralateral cingulate gyrus is compressed Depression of ipsilateral corpus callosum and elevation / compression of contralateral corpus callosum
Subfalcine Herniation
Subfalcine Herniation
Displaced pericallosal artery Ipsilateral cingulate gyrus herniates under falx
Subfalcine Herniation:
Complications and Clinical Signs
Compression of the parafalcine cortex may lead to contralateral leg paresis Anterior cerebral artery infarction may lead to ipsilateral frontal infarcts Increased ICP leads to somnolence
http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case4/CerebralArteryDistribution.htm
Subfalcine Herniation:
Complications
CT Angiogram of patient with subdural hematoma on the right shows displacement of anterior cerebral artery without evidence of infarction
Subfalcine Herniation:
Complications
Right sided mass effect was treated by craniotomy. Hypodensity in the right frontal lobe exemplifies anterior cerebral artery infarct after prolonged subfalcine herniation
Transtentorial Herniation
Descending Ascending
Supratentorial mass effect forces cerebral structures downward through the opening (incisura) of the tentorium
Chronic (hypodens) rightsided subdural hematoma with unilateral descending transtentorial herniation
http://scalpelorsword.blogspot.com/2007/01/droopy-eye.html
http://www.bartleby.com
Kernohan, J.W., & Woltman, H.W. (1929). Incisura of the crus due to contralateral brain tumor. Archives of Neurology and Psychiatry, 21, 274-287
Complications:
Vascular structures at risk
MRI images of the vascular structures around the uncus (posterior cerebral artery and anterior choroidal artery). The latter originates from the anterior cerebral artery and traverses along the uncus dorsally (arrows)
Wiesmann et al. Identification and Anatomic Description of the Anterior Choroidal Artery by Use of 3D-TOF Source and 3DCISS MR Imaging AJNR Am J Neuroradiol 2001; 22: 305-310
Complications:
Vascular structures at risk
Anterior choroidal artery compression may lead to infarcts in the posterior limb of the internal capsule and the lateral aspect of the thalamus Posterior cerebral artery compression leads to cerebellar and occipital lobe infarction but may also cause thalamic infarcts
Complications:
Duret Hemorrhage
Prolonged and progressive transtentorial herniation leads to stretching and eventually rupture of perforating arteries and venules in the brainstem causing punctate hemorrhage
http://rad.usuhs.mil/rad/herniation/herniation.html#intro
Complications:
Duret Hemorrhage
Extensive descending transtentorial herniation resulting from gunshot wound to the head; Initial CT scan shows Duret hemorrhage
Posterior fossa mass forces cerebellar structures upwards through tentorial incisura
Hemorrhagic arteriovenous malformation in the left cerebellar hemisphere with bilateral ascending transtentorial herniation
Right sided hemorrhagic contusions with mass effect in the right cerebellum causing unilateral ascending transtentorial herniation
Posterior fossa mass effect forces cerebellar tonsils downward through the foramen magnum
Tonsillar Herniation
Structures involved
Tonsillar Herniation
Tonsillar Herniation
Anteriorly displaced cervical myelum
Tonsillar Herniation
Special notes
(Subtle) extension of cerebellar tonsils in the spinal canal may be seen in normal individuals or in Chiari I malformation Extension of 5 mm or more below the foramen magnum is considered abnormal
Often coexisting with ascending transtentorial herniation
Aboullez etal. Position of cerebellar tonsils in the normal population and in patients with Chiari I malformation: A quantative approach with MR Imaging. J Comp Assist Tomogr 1985;9: 1033-1036
Tonsillar Herniation
Chiari I malformation with extension of the cerebellum in the upper cervical spinal canal in a patient with a frontal mass
Tonsillar Herniation
Clinical findings / Complications
Compression of brain stem nuclei causes respiratory / cardiac failure, coma, death Compression of posterior inferior cerebellar artery (PICA) may cause cerebellar infarcts
Patients with Chiari I malformation can be symptom free but may experience dysesthesia with cervical flexion: Lhermitte phenomenon
Transcranial Herniation
Fungus Cerebri
Intracranial mass effect forces cerebral structures outward through (iatrogenic) calvarial defect
Transcranial Herniation
Decompressive right frontal craniotomy in two patients with severe right sided mass effect. Cerebral structures herniate through calvarial defect. Note that there is no midline shift. Mass effect is orientated away from contralateral hemisphere.
Transcranial Herniation
Complications
Decompression usually improves patient survival by lowering intracranial pressure and preventing / undoing intracranial herniations
Herniation may lead to infarction of herniated tissue Exposed brain / dura is prone to infection
Miscellaneous
Anterior cranial fossa mass effect forces cerebral structures over the edge of the sphenoid bone into the middle cranial fossa
Cerebral structures bulge through (acquired) skull base defect NO PRESSURE COMPONENTS