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Beucler N, Cungi PJ, Dagain A. Duret Brainstem Hemorrhage After Transtentorial Descending Brain Herniation: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 173:251-262.e4. [PMID: 36868404 DOI: 10.1016/j.wneu.2023.02.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Historically, the occurrence of hemorrhage in the brainstem after an episode of supratentorial intracranial hypertension was described by Henri Duret in 1878. Nevertheless, to date the eponym Duret brainstem hemorrhage (DBH) lacks systematic evidence regarding its epidemiology, pathophysiology, clinical and radiologic presentation, and outcome. METHODS We conducted a systematic literature review and meta-analysis using the Medline database from inception to 2022 looking for English-language articles concerning DBH, in accordance with the PRISMA guidelines. RESULTS The research yielded 28 articles for 32 patients (mean age, 50 years; male/female ratio, 3:1). Of patients, 41% had head trauma causing 63% of subdural hematoma, responsible for coma in 78% and mydriasis in 69%. DBH appeared on the emergency imaging in 41% and on delayed imaging in 56%. DBH was located in the midbrain in 41% of the patients, and in the upper middle pons in 56%. DBH was caused by sudden downward displacement of the upper brainstem secondary to supratentorial intracranial hypertension (91%), intracranial hypotension (6%), or mechanical traction (3%). Such downward displacement caused the rupture of basilar artery perforators. Brainstem focal symptoms (P = 0.003) and decompressive craniectomy (P = 0.164) were potential favorable prognostic factors, whereas an age >50 years showed a trend toward a poor prognosis (P = 0.0731). CONCLUSIONS Unlike its historical description, DBH appears as a focal hematoma in the upper brainstem caused by the rupture of anteromedial basilar artery perforators after sudden downward displacement of the brainstem, regardless of its cause.
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Affiliation(s)
- Nathan Beucler
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France; Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France.
| | | | - Arnaud Dagain
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France; Val-de-Grâce Military Academy, Paris, France
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Tyngkan L, Mahfouz N, Bilal S, Fatima B, Malik N. Duret Hemorrhage after Extradural Hematoma Evacuation–A Rare Entity. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1725213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractTraumatic brainstem injury can be classified as primary or secondary. Secondary brainstem hemorrhage that evolves from raised intracranial pressure (ICP) and transtentorial herniation is referred to as Duret hemorrhage. We report a 25-year-old male who underwent emergency craniotomy, with evacuation of acute epidural hematoma, and postoperatively developed fatal Duret hemorrhage. Duret hemorrhage after acute epidural hematoma (EDH) evacuation is a very rare complication and the outcome is grave in most of the cases.
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Affiliation(s)
- Lamkordor Tyngkan
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Nazia Mahfouz
- Department of Pulmonary Medicine, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Sobia Bilal
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Bazla Fatima
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Nayil Malik
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
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Edlow BL, Threlkeld ZD, Fehnel KP, Bodien YG. Recovery of Functional Independence After Traumatic Transtentorial Herniation With Duret Hemorrhages. Front Neurol 2019; 10:1077. [PMID: 31649617 PMCID: PMC6794605 DOI: 10.3389/fneur.2019.01077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023] Open
Abstract
Historically, Duret hemorrhages have conferred a devastating prognosis. However, recent case reports suggest that cognitive and functional recovery are possible after Duret hemorrhages. Here, we describe a patient who recovered consciousness, communication, and functional independence after Duret hemorrhages caused by traumatic transtentorial herniation. We performed prospective, standardized behavioral assessments, structural MRI scans and stimulus-based functional MRI (fMRI) scans during the first 2 years of recovery. The multimodal assessments revealed reintegration of neural networks mediating language and consciousness, concurrent with the reemergence of functional independence. These observations provide insights into network-based mechanisms of recovery from coma and add to a growing body of evidence indicating that Duret hemorrhages are not invariably associated with a poor prognosis.
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Affiliation(s)
- Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - Zachary D Threlkeld
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, United States
| | - Katie P Fehnel
- Department of Neurosurgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Yelena G Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
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4
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Nguyen HS, Doan NB, Gelsomino MJ, Shabani S, Mueller WM. Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma. Int Med Case Rep J 2016; 9:15-8. [PMID: 26869816 PMCID: PMC4734784 DOI: 10.2147/imcrj.s95809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Secondary 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 presentation A 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. Conclusion In 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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Affiliation(s)
- Ha Son Nguyen
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ninh B Doan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael J Gelsomino
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
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5
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Frassanito P, Markogiannakis G, Di Bonaventura R, Massimi L, Tamburrini G, Caldarelli M. Descending transtentorial herniation, a rare complication of the treatment of trapped fourth ventricle: case report. J Neurosurg Pediatr 2015. [PMID: 26207666 DOI: 10.3171/2015.3.peds14619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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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Affiliation(s)
- Paolo Frassanito
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy; and
| | | | - Rina Di Bonaventura
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy; and
| | - Luca Massimi
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy; and
| | | | - Massimo Caldarelli
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy; and
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Duret haemorrhage with full recovery. Acta Neurochir (Wien) 2015; 157:1337-8; discussion 1338. [PMID: 26136197 DOI: 10.1007/s00701-015-2486-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
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Abstract
Traumatic brain injuries afflict a large number of pediatric patients. The most severe injuries lead to increased intracranial pressure and herniation, with resultant changes in the brainstem. Traumatic brainstem hemorrhages have previously been associated with poor neurological outcome and fatality. However, this report discusses 2 pediatric patients who sustained severe head trauma with subsequent brainstem hemorrhages, and yet experienced good neurological outcome; the possible mechanism is described.
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Affiliation(s)
- Alexandra D Beier
- Division of Pediatric Neurological Surgery, University of Florida Health Jacksonville, Florida; and
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8
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Ishizaka S, Shimizu T, Ryu N. Dramatic recovery after severe descending transtentorial herniation-induced Duret haemorrhage: A case report and review of literature. Brain Inj 2013; 28:374-7. [DOI: 10.3109/02699052.2013.864422] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Duret hemorrhage: demonstration of ruptured paramedian pontine branches of the basilar artery on minimally invasive, whole body postmortem CT angiography. Forensic Sci Med Pathol 2012; 8:436-40. [DOI: 10.1007/s12024-012-9329-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2012] [Indexed: 10/28/2022]
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Park KJ, Kang SH, Lee HK, Chung YG. Brain stem hemorrhage following burr hole drainage for chronic subdural hematoma-case report-. Neurol Med Chir (Tokyo) 2010; 49:594-7. [PMID: 20035135 DOI: 10.2176/nmc.49.594] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 76-year-old man presented with brain stem hemorrhage after burr-hole drainage for bilateral chronic subdural hematomas. Neuroimaging demonstrated resolution of the transtentorial herniation but also detected new brain stem hemorrhage, manifesting as gait disturbance. He recovered after conservative treatment. Asymmetrical and rapid decompression, which leads to vascular disruption and/or sudden increase in cerebral blood flow, was probably responsible for the secondary brain stem hemorrhage. Therefore, simultaneous and bilateral decompression with a slow rate of evacuation of massive bilateral chronic subdural hematomas is recommended to prevent serious complications such as secondary intracranial hematoma.
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Affiliation(s)
- Kyung-Jae Park
- Department of Neurosurgery, Korea University, College of Medicine, Seongbuk-Gu, Seoul, Korea
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Mathai K, Jain A, Singh D, Dutta SGS, Sengupta SK, Harikrishnan V. The enigma of traumatic, behaviourally benign brain stem bleeds: Case report. INDIAN JOURNAL OF NEUROTRAUMA 2009. [DOI: 10.1016/s0973-0508(09)80009-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Carrasco R, Pascual JM, Navas M, Martínez-Flórez P, Manzanares-Soler R, Sola RG. Kernohan-Woltman notch phenomenon caused by an acute subdural hematoma. J Clin Neurosci 2009; 16:1628-31. [PMID: 19766003 DOI: 10.1016/j.jocn.2009.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 01/27/2009] [Accepted: 02/03/2009] [Indexed: 10/20/2022]
Abstract
Uncal herniation through the tentorial notch is occasionally associated with false localizing ipsilateral hemiparesis, known as the Kernohan-Woltman notch phenomenon (KWNP). We report an 81-year-old female who presented with a decreased level of consciousness, a right mydriasis and an ipsilateral motor deficit caused by a large right hemispheric subdural hematoma that was immediately evacuated. The patient recovered well, although her right hemiplegia persisted. A follow-up MRI showed a residual lesion in the left cerebral peduncle, corresponding to KWNP. The presence of such a structural lesion suggests a poor prognosis for recovery from the initial motor deficit.
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Affiliation(s)
- Rodrigo Carrasco
- Department of Neurosurgery, La Princesa University Hospital, C/- Diego de León 62, 28006 Madrid, Spain.
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Stiver SI, Gean AD, Manley GT. Survival with good outcome after cerebral herniation and Duret hemorrhage caused by traumatic brain injury. J Neurosurg 2009; 110:1242-6. [DOI: 10.3171/2008.8.jns08314] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Brainstem hemorrhage can occur as a primary or secondary event in traumatic brain injury (TBI). Secondary brainstem hemorrhage that evolves from raised intracranial pressure and transtentorial herniation is referred to as Duret hemorrhage. Duret hemorrhage following TBI has been considered an irreversible and terminal event. The authors report on the case of a young adult patient with TBI who presented with a low Glasgow Coma Scale score and advanced signs of cerebral herniation. She underwent an urgent decompressive hemicraniectomy for evacuation of an acute epidural hematoma and developed a Duret hemorrhage postoperatively. In accordance with the family's wishes, aggressive TBI monitoring and treatment in the intensive care unit was continued even though the anticipated outcome was poor. After a lengthy hospital course, the patient improved dramatically and was discharged ambulatory, with good cognitive functioning and a Glasgow Outcome Scale score of 4. Duret hemorrhage secondary to raised intracranial pressure is not always a terminal event, and by itself should not trigger a decision to withdraw care. Aggressive intracranial monitoring and treatment of a Duret hemorrhage arising secondary to cerebral herniation may enable a good recovery in selected patients after severe TBI.
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Affiliation(s)
- Shirley I. Stiver
- 1Departments of Neurosurgery and
- 3Brain and Spinal Injury Center, University of California San Francisco, California
| | - Alisa D. Gean
- 1Departments of Neurosurgery and
- 2Radiology, School of Medicine; and
- 3Brain and Spinal Injury Center, University of California San Francisco, California
| | - Geoffrey T. Manley
- 1Departments of Neurosurgery and
- 3Brain and Spinal Injury Center, University of California San Francisco, California
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Kamijo Y, Soma K, Kishita R, Hamanaka S. Duret hemorrhage is not always suggestive of poor prognosis: a case of acute severe hyponatremia. Am J Emerg Med 2005; 23:908-10. [PMID: 16291454 DOI: 10.1016/j.ajem.2005.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Yoshito Kamijo
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Kanagawa 228-8555, Japan.
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