Duret hemorrhage: demonstration of ruptured paramedian pontine branches of the basilar artery on minimally invasive, whole body postmortem CT angiography

Chew, Ka Lip; Baber, Yeliena; Iles, Linda; O’Donnell, Christopher J.

doi:10.1007/s12024-012-9329-y

Cited by 17 publications

(9 citation statements)

References 13 publications

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“…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.…”

supporting

confidence: 63%

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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supporting

confidence: 63%

Duret haemorrhage with full recovery

Bermúdez

Areitio

2015

Acta Neurochir

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“…Duret haemorrhage is a secondary brainstem haemorrhage that occurs in the setting of severe descending transtentorial herniation and is considered a fatal sign that indicates irreversible brain damage [1][2][3][4]. However, some reported Duret haemorrhage cases have demonstrated dramatic recovery [5][6][7][8][9].…”

Section: Introductionmentioning

confidence: 99%

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

Ishizaka¹,

Shimizu²,

Ryu³

2013

Brain Injury

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“…When the brain stem is displaced inferiorly, the basilar artery and its paramedian pontine perforating vessels remain relatively fixed; this may cause the latter to shear and lead to hemorrhage. 1 , 13 On the other hand, since veins are more compressible than arteries, herniation may lead to venous congestion and subsequent infarction at the rostal brain stem draining veins, followed by hemorrhagic conversion. 1 , 13 Interestingly, an element of hemorrhage may be linked to reperfusion injury, as there have been reports of brain stem hemorrhages after surgical decompression.…”

Section: Discussionmentioning

confidence: 99%

“… 1 , 13 On the other hand, since veins are more compressible than arteries, herniation may lead to venous congestion and subsequent infarction at the rostal brain stem draining veins, followed by hemorrhagic conversion. 1 , 13 Interestingly, an element of hemorrhage may be linked to reperfusion injury, as there have been reports of brain stem hemorrhages after surgical decompression. 7 , 9 …”

Section: Discussionmentioning

confidence: 99%

Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma

Nguyen¹,

Doan²,

Gelsomino³

et al. 2016

IMCRJ

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BackgroundSecondary brain stem injury is associated with transtentorial herniation, and manifests as “Duret” hemorrhages. Such an injury has been considered a terminal brain stem event with a high morbidity and mortality, sometimes discouraging continuation of care. However, there have been rare instances where patients have had reasonable recovery. We report another case, emphasizing that such an injury by itself should not deter aggressive measures, as good outcomes remain a possibility.Case presentationA 37-year-old male sustained a right subdural hematoma after a mechanical fall while intoxicated. He presented initially with a Glasgow Coma Scale 15. Three days later, he exhibited acute neurological deterioration to Glasgow Coma Scale 4, requiring intubation and mannitol. Repeat scan demonstrated enlarging right subdural hematoma with worsening shift; brain stem hemorrhage was noted at pontomesencephalic junction. Patient was immediately taken for subdural hematoma evacuation. The following day, patient was able to sluggishly follow commands in all four extremities. He had a short stay for inpatient rehabilitation and underwent autologous cranioplasty at 3 months. On examination, he was awake, alert, and oriented to self, time, and location; he exhibited dysarthric speech, right ptosis, but followed commands in all four extremities with no focal motor weakness.ConclusionIn contrast to the common belief, patients suffering from a “Duret” hemorrhage can still have a good outcome. “Duret” hemorrhages may not represent a fatal injury. The finding from this paper suggests the finding of “Duret” hemorrhages on imaging should not deter aggressive measures especially in patients with lesions causing significant mass effects. Overall clinical status should drive surgical options and clinical course.

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Duret hemorrhage: demonstration of ruptured paramedian pontine branches of the basilar artery on minimally invasive, whole body postmortem CT angiography

Cited by 17 publications

References 13 publications

Duret haemorrhage with full recovery

Duret haemorrhage with full recovery

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

Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma

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