Patients who present with a depressed level of consciousness, new onset or worsening headaches, nausea, vomiting, new or worsening focal neurological deficits or patients who have signs of raised intracranial pressure on imaging studies such as sulcal effacement, effacement of cisterns, midline shift should be managed emergently. ICH for ICH is a great way of remembering the clinical signs of uncal herniation: ICH and the classic Cushing’s triad, ICH (Irregular breathing, Cardiac-Bradycardia and Pressure-Hypertension). Tonsillar herniation is treated with posterior decompression, and failure to treat promptly results in respiratory arrest and death. 4 Uncal herniation is treated with decompressive hemicraniectomy or removal of the mass lesion, and failure to treat this condition promptly can result in persistent third nerve palsy, hemiparesis, coma, or death. For lesions such as acute epidural hematomas the outcomes are excellent whereas in diffuse traumatic brain injury benefits are less certain. When stable, an emergent CT of the head should be urgently arranged to determine the etiology of the herniation.ĭefinitive treatment is with emergent decompression at early stages, deficits may be reversible, but overall efficacy of decompression for herniation is dependent on the etiology of the herniation. 3 Neurosurgery may place an external ventricular drain (EVD) in order to divert CSF and reduce intracranial pressure. 2 Hyperventilation to a PCO2 of 30-35 mmHg may be used as a temporizing measure. Non-operative methods for ICP management include elevating the head of the bed to 30 degrees, osmotic agents such as hypertonic saline or mannitol, and sedation with opioids or paralytics. Pay special attention to the patient with high intracranial pressure and bradycardia.Ī patient presenting with either of these constellations of symptoms should have urgent management of their intracranial pressure and immediate neurosurgical consultation. Tonsillar herniation causes the Cushing reflex, consisting of irregular breathing, bradycardia, and hypertension. This results in compression of the brainstem, which contains many important homeostatic centers including centers that regulate breathing and consciousness. Tonsillar herniation is a posterior fossa herniation characterized by herniation of the cerebellar tonsils through the foramen magnum. The significance of decreased level of consciousness should not be ignored in these patients. The earliest reliable sign is the ipsilateral blown pupil. Uncal herniation results in a classic uncal herniation syndrome involving ipsilateral cranial nerve III palsy (fixed, dilated, so-called ‘blown’ pupil), coma, and contralateral hemiparesis. The uncus herniates medially into the tentorial notch, causing compression on the 3rd nerve then brainstem as it progresses. Uncal herniation is the herniation of the uncus, which is a part of the anteromedial portion of the temporal lobe. These are the supratentorial uncal herniation syndrome and the infratentorial tonsillar herniation. There are two classic brain herniation syndromes that should be considered for patients presenting acutely. However spontaneous intracerebral hemorrhage (ICH) and traumatic brain injury (TBI) are common causes of herniation in the acute setting this is frequently related to trauma ± hemorrhage. 1 Any mass lesion, including hemorrhage, tumor, vasogenic or cytotoxic edema, trauma or infection can cause herniation. Different types of brain herniation can occur depending on the location of mass effect and how rapidly this mass effect develops. Brain herniation is a catastrophic sequela of increased intracranial pressure (ICP) or local mass effect from intracranial lesions.
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