0:01

I'd like to show this pretty dramatic case

0:03

of a patient who had an intraparenchymal

0:06

hemorrhage to identify the different patterns

0:10

that we see with herniation of the brain.

0:14

So, as we go from below, we immediately see hemorrhage

0:17

in the fourth ventricle, and we see hemorrhage

0:21

in the brainstem, and we see hemorrhage in the

0:24

lateral ventricles. We see hemorrhage in the third

0:27

ventricle. Then, we see a big parenchymal hematoma,

0:32

which is actually centered in the thalamus.

0:34

I would opine that this is most likely a

0:38

hypertensive bleed as opposed to trauma.

0:41

And even if the patient had trauma, I might

0:43

suggest that, well, maybe the trauma was

0:46

after the patient had a hypertensive bleed.

0:50

Now, this patient was normotensive, and there was trauma.

0:52

So, this was most likely a

0:55

hemorrhage associated with the trauma.

0:57

The etiology of the hemorrhage is not as important as

1:00

what we are seeing with regard to right-to-left shift.

1:04

So, again, in order to help the neurosurgeons

1:08

define whether or not this is an operative

1:10

case, we want to see whether there's greater

1:12

than five millimeters of right-to-left shift.

1:15

So, we make our line at the level of

1:17

the septum pellucidum, and then we measure

1:20

from the septum pellucidum to the midline.

1:22

This patient has 11 millimeters of right-to-left shift.

1:27

That's more than five.

1:28

This is going to be a neurosurgical case.

1:31

We see that the patient has some

1:32

falcine herniation from right to left.

1:35

And at the level of the uncus,

1:39

we see this low-density uncus.

1:41

This is an uncus that is

1:43

being compressed by the tentorium, and it is

1:49

associated with hemorrhage in the brainstem.

1:53

The hemorrhage in the brainstem is what is known

1:56

as Duret hemorrhage—that's D-U-R-E-T.

2:00

This is a phenomenon that occurs with herniation,

2:02

transtentorial herniation, in which you have leakage

2:06

of these small blood vessels in the midbrain

2:09

and upper pons that is associated with the herniation.

2:13

So, you also note that the temporal horn here is

2:17

markedly dilated and filled with blood products.

2:20

The temporal horn on the

2:21

contralateral side is also enlarged.

2:24

This is another phenomenon that can be seen

2:27

when you have transtentorial uncal herniation.

2:31

So, this uncus is going around the corner

2:34

and down into the posterior fossa,

2:38

as this low-density area just anterior to the brainstem.

2:44

So, subfalcine herniation, right-to-left

2:47

shift, uncal herniation, transtentorial

2:51

herniation, with one of the complications

2:53

being Duret hemorrhages of the brainstem.

2:56

With this degree of right-to-left shift, we want

2:59

to pay a lot of attention to the medial occipital

3:03

lobe in order to early detect whether or not the

3:06

patient is picking off that posterior cerebral

3:09

artery, which can lead to an occipital lobe infarct.

3:12

With the subfalcine herniation, we want to look

3:16

carefully at the medial frontal lobe to see

3:20

whether that subfalcine herniation is picking off

3:23

anterior cerebral artery (ACA) branches that may lead

3:28

to an ACA infarct of the medial frontal lobe.

3:33

As of right now, I do not see that.