Cerebral Herniation

Aka: Cerebral Herniation, Uncinate Herniation, Uncal Herniation, Brainstem Herniation, Brain Stem Herniation, Cerebellar Herniation, Transtentorial Herniation, Acute Severe Intracranial Pressure Management

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II. Causes

  1. Intracranial Mass
  2. Cerebral edema
  3. Intracranial Hemorrhage
    1. Epidural Hematoma
    2. Acute Subdural Hematoma

III. Mechanism

  1. Tentorium cerebelli divides supratentorial (Cerebrum) from infratentorial
  2. Peri-tentorium structures include Midbrain, CN III, medial Temporal Lobe
    1. Parasympathetic fibers (constrict pupil normally) lie on outside of CN III and are more easily injured
    2. Oculomotor Nerve (CN III) compression results in Pupil Dilation (Blown Pupil)

IV. Signs

  1. Unilateral, ipsilateral dilated pupil (Blown Pupil)
  2. Contralateral limb weakness or Hemiparesis
  3. Posturing
    1. Decorticate Posturing (arm flexion)
    2. Decerebrate Posturing (arm and leg extension)

V. Management

  1. General measures
    1. See Increased Intracranial Pressure in Closed Head Injury
      1. Includes head of be elevation, airway and Ventilator management, Mannitol
    2. See Severe Head Injury Management
    3. See Status Epilepticus
  2. CNS Hemorrhage (acute Subdural Hematoma, Epidural Hematoma)
    1. See Skull Trephination

VI. References

  1. (2012) ATLS, ACS p. 152-3
  2. DeBlieux in Herbert (2016) EM:Rap 16(5): 8-10

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