🚨 Brain Herniation Syndromes – Emergency Management
🫁 ABC, Oxygen, urgent imaging, neurosurgical discussion, ITU 🚑 Transfer to neurosurgical centre (may need intubation → anaesthetic review) 💧 Buy time: Mannitol 20% 0.25–0.5 g/kg IV over 10–20 min (works in 20–30 min, lasts up to 6h) 🧠 Tumour oedema: Dexamethasone 10 mg IV ⚡ Seizure prophylaxis: IV Levetiracetam

📖 Introduction

🪨 Brain is encased within rigid skull with falx cerebri & tentorium cerebelli.
⚠️ Raised ICP or mass effect → tissue pushed across partitions = herniation.
🧩 Life-threatening → rapid recognition + neurosurgical emergency.
6 main types of brain herniation syndromes.

🧩 Herniation Syndromes

No.	Syndrome	Segment Affected	Details
[1]	➡️ Uncal (Transtentorial) Herniation	Uncus of temporal lobe, CN III, PCA	👁️ Ipsilateral CN III palsy → dilated pupil, ptosis, “down & out” eye. 🟤 PCA compression → contralateral homonymous hemianopia. ❗ False localising sign: contralateral hemiparesis (Kernohan’s notch). 💉 Severe: Duret haemorrhages in midbrain/pons.
[2]	⬇️ Central Transtentorial Herniation	Thalamus → brainstem	😴 Progressive coma from downward displacement. 👁️ Bilateral pupil changes. 🧍 Posturing: decorticate → decerebrate.
[3]	↔️ Subfalcine Herniation	Cingulate gyrus	🩸 Mass pushes brain under falx cerebri. ⚡ ACA compression → contralateral leg weakness. 🖥️ Midline shift on CT.
[4]	🕳️ Transcalvarial Herniation	Cortex	Brain herniates through skull defect (e.g. craniectomy, fracture). Brain bulges outside skull until oedema resolves.
[5]	⬆️ Upward Transtentorial Herniation	Cerebellum upward	Occurs after EVD in posterior fossa lesion. ⚠️ Severe brainstem compression.
[6]	⬇️ Transforaminal (Tonsillar “Coning”)	Cerebellar tonsils & medulla	Tonsils forced through foramen magnum. 🫁 Medulla compression → bradycardia, irregular respiration, cardiac arrest. Often terminal event in severe ICP.

📸 Key Examples

Uncal Herniation with Duret Hemorrhages:

Transcalvarial Herniation:

⚠️ Clinical Signs of Raised ICP

👁️ Fixed, dilated pupil.
🤕 Severe headache, confusion, drowsiness.
😴 Reduced GCS / coma.
✋ Contralateral weakness/hemiplegia.
💓 Cushing’s triad: bradycardia + hypertension + irregular breathing.
🫁 Respiratory depression/arrest.

🧪 Investigations

CT/MRI brain urgently to confirm herniation & cause.

🩺 Management

💉 Neurosurgery: decompression, clot evacuation.
💧 Osmotic therapy: Mannitol / hypertonic saline.
🚨 Emergency ventriculostomy: CSF drainage.
🌅 Palliation: if no chance of recovery.

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Brain Herniation syndromes