Diffusion-weighted magnetic resonance imaging in a case of Kernohan's notch phenomenon

Uesugi, Seiji; Suehiro, Eiichi; Nakayama, Hiromichi; Suzuki, Michiyasu

doi:10.1007/s00701-010-0732-4

Cited by 12 publications

(6 citation statements)

References 5 publications

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“…In a subacute setting, the lesion in the cerebral peduncle presented hypointense signal in T1-weighted sequence [ 28 , 36 , 40 , 41 , 50 , 62 ] and hyperintense signal in T2-weighted sequ ence [ 2 , 3 , 5 , 10 , 13 , 20 , 21 , 23 , 28 , 33 , 34 , 36 , 37 , 39 - 41 , 46 , 50 , 52 - 55 , 61 , 63 ] and in fluid-attenuated inversion recovery (FLAIR) sequence [ 2 , 4 , 14 , 19 - 21 , 34 , 37 , 60 ]. It displayed restricted diffusion with brightness in diffusion-weighted imaging (DWI) [ 7 , 9 , 14 , 21 , 34 , 39 , 52 - 54 ], and apparent diffusion coefficient low values [ 9 , 54 ]. Last, it presented hypointense signal in gradient echo sequence [ 5 ] and evidence of blood-brain barrier rupture in post-contrast T1-weighted imaging [ 21 ].…”

Section: Resultsmentioning

confidence: 99%

“…In a subacute setting, the focal area of cerebral peduncle notched against the free edge of the tentorium displayed the typical features of ischemic stroke with restricted diffusion [ 9 , 54 ] and edema in FLAIR sequence [ 2 , 4 , 14 , 19 - 21 , 34 , 37 , 60 ]. Nevertheless, most of the time the lesion was facing the free edge of the cerebellar tentorium and did not correspond to the systematized anterolateral territory supplied by the PCA, which usually causes hemiparesis or hemiataxia [ 32 ].…”

Section: Discussionmentioning

confidence: 99%

“…Reports concerning patients suffering from KWNP ranged from 1990 to 2020 [2][3][4][5][6][7][8][9][10][13][14][15]17,[19][20][21]23,[26][27][28][29][30][33][34][35][36][37][39][40][41][43][44][45][46]49,50,[52][53][54][55][59][60][61][62][63] . The database research yielded 220 articles and 149 after removal of duplicates.…”

Section: Database Researchmentioning

confidence: 99%

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The Kernohan-Woltman Notch Phenomenon : A Systematic Review of Clinical and Radiologic Presentation, Surgical Management, and Functional Prognosis

Beucler

Cungi

Baucher

et al. 2022

J Korean Neurosurg Soc

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The Kernohan-Woltman notch phenomenon (KWNP) refers to an intracranial lesion causing massive side-to-side mass effect which leads to compression of the contralateral cerebral peduncle against the free edge of the cerebellar tentorium. Diagnosis is based on “paradoxical” motor deficit ipsilateral to the lesion associated with radiologic evidence of damage to the contralateral cerebral peduncle. To date, there is scarce evidence regarding KWNP associated neuroimaging patterns and motor function prognostic factors. A systematic review was conducted on Medline database from inception to July 2021 looking for English-language articles concerning KWNP, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The research yielded 45 articles for a total of 51 patients. The mean age was 40.7 years-old and the male/female sex ratio was 2/1. 63% of the patients (32/51) suffered from head trauma with a majority of acute subdural hematomas (57%, 29/51). 57% (29/51) of the patients were in the coma upon admission and 47% (24/51) presented pupil anomalies. KWNP presented the neuroimaging features of compression ischemic stroke located in the contralateral cerebral peduncle, with edema in the surrounding structures and sometimes compression stroke of the cerebral arteries passing nearby. 45% of the patients (23/51) presented a good motor functional outcome; nevertheless, no predisposing factor was identified. A Glasgow coma scale (GCS) of more than 3 showed a trend (p=0.1065) toward a better motor functional outcome. The KWNP is a regional compression syndrome oftentimes caused by sudden and massive uncal herniation and leading to contralateral cerebral peduncle ischemia. Even though patients suffering from KWNP usually present a good overall recovery, patients with a GCS of 3 may present a worse motor functional outcome. In order to better understand this syndrome, future studies will have to focus on more personalized criteria such as individual variation of tentorial notch width.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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The Kernohan-Woltman Notch Phenomenon : A Systematic Review of Clinical and Radiologic Presentation, Surgical Management, and Functional Prognosis

Beucler

Cungi

Baucher

et al. 2022

J Korean Neurosurg Soc

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“…Magnetic resonance imaging was not used in any of our patients, hence it is difficult to tell if the delayed recovery of the third case could have been due to some signal changes in her crus cerebri. Some others believe KWNP involves the mechanism of cytotoxic edema [9].…”

Section: Discussionmentioning

confidence: 99%

Kernohan-Woltman Notch Phenomenon in Chronic Subdural Hematoma: An under-Diagnosed Phenomenon?

Asante-Bremang

Alhassan

Ofori

et al. 2021

JAMMR

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Introduction: Kernohan-Woltman notch phenomenon is a neurological picture of mydriasis and hemiparesis/ hemiplegia ipsilateral to a supratentorial mass lesion causing compression of the contralateral cerebral peduncle against the tentorial edge. The aim of this paper is to report series of cases from a low volume centre of neurosurgical care and highlight the fact that Kernohan’s notch phenomenon, although, reported to be quite rare but it’s not uncommon and to also look out for this phenomenon to avoid wrong site surgeries. Presentation of Cases: We report four cases of chronic subdural hematoma presenting with Kernohan- Woltmann notch phenomenon. The patients include: a young alcoholic who was found in a gutter after binge drinking, a middle aged man who was accidentally hit on the head with a car tire jack, an elderly female with no history of trauma, a fall nor use of anticoagulant and an elderly male, a diabetic. All four patients had emergency burr hole and drainage of subdural hematoma. Discussion: This incidence of this phenomenon among patients with chronic subdural hematoma is rarely reported in the literature, however, a low volume centre for neurosurgical services like ours has seen five cases in a short period of time. Conclusion: This paradoxical neurological sign is probably under-diagnosed judging from the number of cases diagnosed in a low volume center like ours.

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“…45 hyperintense signal within the cerebral peduncle owing to the restriction in the apparent diffusion coefficient (ADC) map during the acute stage of this phenomenon probably reflects the presence of cytotoxic edema, as it attenuates or disappears in control studies. 42 Partial or total recovery from motor deficit, even in patients in whom a complete disruption of a normally decussated corticospinal tract has been demonstrated using diffusion tensor imaging, 29,33,37 can be explained by the resolution of cytotoxic edema beneath the peduncle notch. This concept is supported by Kernohan and Woltman's original histological studies confirming the disruption of myelin sheaths at the level of the injured area behind the notch, whereas most of the corresponding axons of the corticospinal tract were spared from destruction.…”

Section: Ipsilateral Hemiparesis: Past Present and Futurementioning

confidence: 99%

Ipsilateral hemiparesis: the forgotten history of this paradoxical neurological sign

Carrasco

Castro-Dufourny

Millán³

et al. 2019

Neurosurgical Focus

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OBJECTIVEEstablishing the neurological localization doctrine for the contralateral hemispheric control of motor functions in the second half of the 19th century, researchers faced the challenge of recognizing false localizing signs, in particular paradoxical or ipsilateral hemiparesis (IH). Despite tremendous progress in current methods of neuroradiological and electrophysiological exploration, a complete understanding of this phenomenon has yet to be attained.METHODSThe authors researched the well-described cases of hemiparesis/hemiplegia ipsilateral to an intracranial lesion published in the scientific literature in the pre-MRI era (before 1980). A comprehensive review of the physiopathological mechanisms proposed for paradoxical hemiparesis throughout this period, as well as the pathological evidence substantiating them, is provided.RESULTSA collection of 75 patients with hemiparesis/hemiplegia ipsilateral to the primary intracranial lesion reported between 1858 and 1979 were eligible for analysis. Most cases occurred in adults with supratentorial, slowly developing, extraparenchymatous mass lesions, such as neoplasms (38%) or chronic subdural hematomas (36%). Physiopathological theories proposed by the neurologists who investigated IH can be grouped into 4 major concepts: 1) lack of anatomical decussation of the corticospinal tract; 2) impaired functional activation of the contralateral hemisphere by the lesioned dominant hemisphere through the callosal connections; 3) Kernohan’s notch phenomenon, or mechanical injury of the contralateral cerebral peduncle against the free edge of the tentorium; and 4) cerebrovascular dysfunction involving the contralateral hemisphere owing to kinking and mechanical flattening of the carotid artery contralateral to the primary intracranial lesion.CONCLUSIONSIH represents a still underdiagnosed paradoxical neurological phenomenon. With the aid of modern neuroradiological and neurophysiological methods, Kernohan’s peduncle notch mechanism has been confirmed to cause IH in many of the cases reported in recent decades. Nevertheless, alternative functional and/or vascular mechanisms must be investigated further for unexplained IH cases, in particular for transitory IH without evidence of peduncle injury. The historical theories reviewed in this paper represent a conceptual framework that may be helpful for this purpose.

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Diffusion-weighted magnetic resonance imaging in a case of Kernohan's notch phenomenon

Cited by 12 publications

References 5 publications

The Kernohan-Woltman Notch Phenomenon : A Systematic Review of Clinical and Radiologic Presentation, Surgical Management, and Functional Prognosis

The Kernohan-Woltman Notch Phenomenon : A Systematic Review of Clinical and Radiologic Presentation, Surgical Management, and Functional Prognosis

Kernohan-Woltman Notch Phenomenon in Chronic Subdural Hematoma: An under-Diagnosed Phenomenon?

Ipsilateral hemiparesis: the forgotten history of this paradoxical neurological sign

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