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

Abstract

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.

Recovery of Functional Independence After Traumatic Transtentorial Herniation With Duret Hemorrhages

“…While the contribution of intensive rehabilitation to recovery from severe TBI, and particularly traumatic Duret hemorrhages, is unknown, it is possible that the patient benefited from extensive inpatient rehabilitation, careful serial assessment, and a multidisciplinary approach to treatment (38). Indeed, in prior rare reports of recovery from Duret hemorrhages caused by traumatic transtentorial herniation, the patients received multidisciplinary rehabilitative care after discharge from the ICU (12–14). It is also notable that the Duret hemorrhages were not detected by CT.…”

“…Since Henri Duret's 1878 description of brainstem hemorrhages caused by transtentorial herniation (2), Duret hemorrhages have frequently been associated with death, prolonged disorders of consciousness, or devastating functional disability (3–6). However, recent case reports suggest that cognitive and functional recovery are possible after Duret hemorrhages (7–14), including in patients with traumatic brain injury (TBI) (12–14). These reports raise the possibility that historical perceptions about the devastating prognostic implications of Duret hemorrhages may be related to a self-fulfilling prophecy, whereby a radiologic predictor is linked to a poor outcome due to withdrawal of life-sustaining therapy, even if no biological mechanism for such an association exists (15, 16).…”

Duret Hemorrhage after Extradural Hematoma Evacuation–A Rare Entity

“…There have been rare instances in the literature that document good functional outcomes. 11 Primary parenchymal injury may also have a significant influence on the prognosis than Duret hemorrhage alone as suggested by Ishizaka et al 9…”

“…As the brainstem moves downward, stretching and disruption of paramedian pontine perforating arteries may directly lead to hemorrhage. 11 On the other hand, since veins are more compressible than arteries, a herniation may lead to venous congestion and subsequent hemorrhagic infarction at the rostral brain stem. 9 10 However, an element of hemorrhage may be linked to reperfusion injury also, as there have been reports of brain stem hemorrhages after surgical decompression.…”

Delayed neurological improvement in a patient with Duret hemorrhage secondary to an acute subdural hematoma: illustrative case

“…Alternatively, or perhaps in tandem, there may also be venous injury resulting in venous infarct and hemorrhage. 4 , 5 These are a distinct entity from primary brainstem hemorrhages occurring at time of impact; however, they can be difficult to distinguish as Duret hemorrhages have been diagnosed within 30 minutes of initial injury. 6 Duret hemorrhages are typically midline and paramedian, in the distribution of the perforating pontine branches.…”