Neuroimaging Cases 010

Brain Herniation Syndromes

Today we present the next cases in our Neuroimaging Case Studies Series in which we share a clinical case, brief literature review, and concise summary recommendations.

Images, text and cases collated by Natalie Rall MD, Teresa Crow MD, L. Erin Miller MD, Troy Carnwath MD, and Scott DiMeo MD. First published on EMGuideWire.com and peer reviewed by Professor Michael Gibbs.

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Summary of Brain Herniation Syndromes

• Brain herniation is defined as a shift of brain tissue from its normal location into an adjacent space.
• Oedema, tumours, or haemorrhage are causes of brain herniation secondary to an increase in volume and intracranial pressure.
• Brain herniation may cause brain pressure necrosis, compress cranial nerves and vessels, cause haemorrhage or ischaemia, and obstruct the normal circulation of CSF, producing hydrocephalus.
• Acute herniations (e.g. haemorrhage) usually requires immediate intervention, while non-emergency management may be appropriate in chronic herniations (e.g. tumour) depending on symptoms. 

By recognizing the CT findings of brain herniation, the acute care clinician is in a unique position to make critical decisions and initiate critical actions that may include one of more of the following:

• Immediate consultation of a neurosurgeon
• Transfer to a center with neurosurgical capabilities
• Haemodynamic stabilization to maintain cerebral perfusion
• Intubation using a neuroprotective strategy
• Treatment with hyperosmolar therapies
• Reversal of anticoagulation

Today we present 13 cases covering the following brain herniation syndromes:

• Uncal herniation
• Transfalcine herniation
• Tonsillar herniation
• Cerebellar herniation
• Tension pneumocephalus

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References

• Johnson PL, Eckard DA, Chason DP, Brecheisen MA, Batnitzky S. Imaging of acquired cerebral herniations. Neuroimaging Clin N Am. 2002 May;12(2):217-28.
• Byard RW. Patterns of cerebral and cerebellar herniation. Forensic Sci Med Pathol. 2013 Jun;9(2):260-4. 
• Riveros Gilardi B, Muñoz López JI, Hernández Villegas AC, Garay Mora JA, Rico Rodríguez OC, Chávez Appendini R, De la Mora Malváez M, Higuera Calleja JA. Types of Cerebral Herniation and Their Imaging Features. Radiographics. 2019 Oct;39(6):1598-1610.
• Parish JM, Driscoll J, Wait SD, Gibbs M. Delayed Traumatic Tension Pneumocephalus: A Case Report. J Emerg Med. 2020 Dec;59(6):e217-e220.
• Tadevosyan A, Kornbluth J. Brain Herniation and Intracranial Hypertension. Neurol Clin. 2021 May;39(2):293-318. 

This neuroimaging interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center. The goal is to promote widespread mastery of CXR interpretation. There is no personal health information [PHI] within, and ages have been changed to protect patient confidentiality.