Dramatic recovery after severe descending transtentorial herniation-induced Duret haemorrhage: A case report and review of literature

Ishizaka, Shunsuke; Shimizu, Tadashi; Ryu, Nobutoshi

doi:10.3109/02699052.2013.864422

Cited by 16 publications

(17 citation statements)

References 14 publications

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“…32 The traumatic brain injury literature contains several reports of patients making a good recovery (Glasgow Outcome Scale score ≥ 4) from Duret hemorrhage. 9,21,28 As in the current case, these reported lesions were located in the central pons, which may have limited damage to the reticular formations located in the dorsal pontine tegmentum. 9 This location is likely to affect the lateral gaze centers, the medial longitudinal fasciculi, and/or the oculomotor nuclei, which may explain the diplopia observed in those who recover.…”

Section: Discussionsupporting

confidence: 51%

“…9,21,28 As in the current case, these reported lesions were located in the central pons, which may have limited damage to the reticular formations located in the dorsal pontine tegmentum. 9 This location is likely to affect the lateral gaze centers, the medial longitudinal fasciculi, and/or the oculomotor nuclei, which may explain the diplopia observed in those who recover. 21 The present case illustrates the importance of accurately identifying and treating intracranial hypotension, as even the sickest patients with this syndrome can make marked recoveries despite poor neurological examinations and discouraging findings on brain imaging.…”

Section: Discussionsupporting

confidence: 51%

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Reversible coma and Duret hemorrhage after intracranial hypotension from remote lumbar spine surgery: case report

Bonow¹,

Bales²,

Morton³

et al. 2016

SPI

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Intracranial hypotension is a rare condition caused by spontaneous or iatrogenic CSF leaks that alter normal CSF dynamics. Symptoms range from mild headaches to transtentorial herniation, coma, and death. Duret hemorrhages have been reported to occur in some patients with this condition and are traditionally believed to be associated with a poor neurological outcome. A 73-year-old man with a remote history of spinal fusion presented with syncope and was found to have small subdural hematomas on head CT studies. He was managed nonoperatively and discharged with a Glasgow Coma Scale score of 15, only to return 3 days later with obtundation, fixed downward gaze, anisocoria, and absent cranial nerve reflexes. A CT scan showed Duret hemorrhages and subtle enlargement of the subdural hematomas, though the hematomas remained too small to account for his poor clinical condition. Magnetic resonance imaging of the spine revealed a large lumbar pseudomeningocele in the area of prior fusion. His condition dramatically improved when he was placed in the Trendelenburg position and underwent repair of the pseudomeningocele. He was kept flat for 7 days and was ultimately discharged in good condition. On long-term follow-up, his only identifiable deficit was diplopia due to an internuclear ophthalmoplegia. Intracranial hypotension is a rare condition that can cause profound morbidity, including tonsillar herniation and brainstem hemorrhage. With proper identification and treatment of the CSF leak, patients can make functional recoveries.

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Section: Discussionsupporting

confidence: 51%

Section: Discussionsupporting

confidence: 51%

Reversible coma and Duret hemorrhage after intracranial hypotension from remote lumbar spine surgery: case report

Bonow¹,

Bales²,

Morton³

et al. 2016

SPI

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“…Prognosis is usually fatal as it affects vital regions of the brain stem. Nevertheless, survivors of this kind of haematoma have been reported [5].We report a patient who did not only survive, but presented with minor symptomatology and no sequelae after suffering a Duret haemorrhage. A 64-year-old man, with no previous disease, presented with postural headache and diplopia after spinal trauma when falling downstairs.…”

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confidence: 89%

“…Prognosis is usually fatal as it affects vital regions of the brain stem. Nevertheless, survivors of this kind of haematoma have been reported [5].…”

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Duret haemorrhage with full recovery

Bermúdez

Areitio

2015

Acta Neurochir

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Dear Editor, Duret haemorrhage usually occurs in the mesencephalicprotuberantial union, appearing after transtentorial herniation. It is related to either brain stem compression by tentorial herniation or its rapid (usually surgical) decompression after herniation. Prognosis is usually fatal as it affects vital regions of the brain stem. Nevertheless, survivors of this kind of haematoma have been reported [5].We report a patient who did not only survive, but presented with minor symptomatology and no sequelae after suffering a Duret haemorrhage. A 64-year-old man, with no previous disease, presented with postural headache and diplopia after spinal trauma when falling downstairs. Examination showed an isolated VI nerve palsy. Cerebral magnetic resonance imaging (MRI) showed bilateral subdural hygromas and signs of hypotension in the cerebrospinal fluid (CSF). Computed tomography (CT) myelography confirmed CSF fistula at the D10-D11 vertebral level. He was treated with an epidural blood patch and recovered partially. Four days after discharge, he was admitted to the emergency room with disorientation, with alteration of consciousness (Glasgow Coma Scale E2V3M6), normal reactive pupils and no neurological deficit. Cranial CT scan showed fresh bleeding into the previous bilateral chronic subdural collections, with transtentorial herniation. He underwent urgent bilateral evacuation of the haematomas through burr holes.Postoperatively, he showed left palpebral ptosis and complete palsy of the third cranial (oculomotor) nerve, with pupillary light reflex sparing and no other neurological symptom. Radiological examination showed a haematoma in the mesencephalic-protuberantial union, as well as persistence of right subdural haematoma (Fig. 1a). After clinical worsening and re-operation for right subdural haematoma drainage, he was discharged with good recovery. Eight months later, he remained asymptomatic and the neurological examination was normal. Follow-up imaging showed disappearance of mesencephalic haematoma and subdural collection.In the nineteenth century, Henri Duret described haemorrhagic lesions in the brain stem after increasing intracranial pressure [3]. It then became the eponym for ventromedial and paramedian haemorrhages in the mesencephalon and highest part of the pons that appear after transtentorial herniation.The pathophysiology of these haemorrhages is not entirely clear. The most widespread current theory states that caudal displacement of the brain stem during herniation causes displacement of the basilar artery, which is attached to the circle of Willis, and rupture of small pontine branches. Recent studies with post-mortem CT angiography support this theory [2]. However, venous bleeding in perivascular spaces seems the most likely origin in the present case.Abrupt decompression of subdural haematomas has been directly related to the development of brain stem secondary haemorrhages. Consequently, some authors propose, as far as possible, gradual and, if bilateral, simultaneous decompression of subd...

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“…This phenomenon usually results from increased pressure in the supratentorial compartment that is related to the presence of a mass lesion. 5,11,14 More rarely, DTH has been described in the absence of mass lesion as a complication of rapid correction of hyponatremia, with subsequent swollen brain parenchyma, or lumbar CSF drainage in the presence of open skull. 13,16,18 If the supratentorial pressure is not promptly relieved, the evolution of this condition may lead to acute sufferance (i.e., distortion and compression) of the brainstem, which is associated with a dismal prognosis.…”

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Descending transtentorial herniation, a rare complication of the treatment of trapped fourth ventricle: case report

Frassanito

Markogiannakis

Bonaventura

et al. 2015

PED

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Descending transtentorial herniation (DTH) is a complication of raised pressure in the supratentorial compartment, usually resulting from mass lesion of several etiologies. The authors report an exceptional case of DTH complicating the implant of a CSF shunting device in the trapped fourth ventricle of a 17-year-old boy in whom a second CSF shunting device had been implanted for neonatal posthemorrhagic and postinfectious hydrocephalus. The insidious clinical and radiological presentation of DTH, mimicking a malfunction of the supratentorial shunt, is documented. Ultimately, the treatment consisted of removal of the infratentorial shunt and endoscopic acqueductoplasty with stenting. The absence of supratentorial mass lesion and other described etiologies of DTH prompted the authors to speculate on the hydrodynamic pathogenesis of DTH in the present case.

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Dramatic recovery after severe descending transtentorial herniation-induced Duret haemorrhage: A case report and review of literature

Abstract: Therefore, patients with Duret haemorrhage of the mid-brain caused by simple subdural haematoma presenting with bilateral oculomotor palsy, including bilateral pupillary dilation, may not always have a poor prognosis.

Cited by 16 publications

References 14 publications

Reversible coma and Duret hemorrhage after intracranial hypotension from remote lumbar spine surgery: case report

Reversible coma and Duret hemorrhage after intracranial hypotension from remote lumbar spine surgery: case report

Duret haemorrhage with full recovery

Descending transtentorial herniation, a rare complication of the treatment of trapped fourth ventricle: case report

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