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Friedman-Korn T, Weill C, Ben-Haim S, Arkadir D. Delayed levodopa-responsive parkinsonism following acute midbrain injury. J Neurol Sci 2024; 459:122983. [PMID: 38574438 DOI: 10.1016/j.jns.2024.122983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/26/2024] [Accepted: 03/31/2024] [Indexed: 04/06/2024]
Abstract
Acute midbrain injury may cause both hyperkinetic movement disorders and parkinsonism. The temporal interval between the insult and the emergence of hyperkinetic disorders can last years. A delayed appearance of parkinsonism, on the other hand, was rarely described. We present three cases of male patients (50-, 58- and 28-year-old) who developed levodopa-responsive parkinsonism 20, 8 and two years, respectively, after acute brain insult involving the midbrain. Insults included subcortical intracerebral hemorrhage dissecting into the midbrain, embolic basilar occlusion and trauma. A fluorodopa scan, performed in two cases, revealed reduced striatal uptake. All individuals improved on low doses of levodopa and developed motor fluctuations shortly after levodopa was introduced. We conclude that delayed, levodopa-responsive parkinsonism following midbrain injury should be recognized in the relevant clinical setup. Possible mechanisms include age-related loss of dopaminergic neurons superimposed on acute injury and secondary neurodegeneration.
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Affiliation(s)
- Tali Friedman-Korn
- Department of Neurology, Hadassah Medical Center and the Faculty of Medicine, The Hebrew University, Jerusalem, Israel.
| | - Caroline Weill
- Department of Neurology, Hadassah Medical Center and the Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Simona Ben-Haim
- Department of Nuclear Medicine, Hadassah Medical Center and the Faculty of Medicine, The Hebrew University, Jerusalem, Israel; University College London, London, UK
| | - David Arkadir
- Department of Neurology, Hadassah Medical Center and the Faculty of Medicine, The Hebrew University, Jerusalem, Israel
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Carrasco-Moro R, Martínez-San Millán JS, Pérez-Pérez M, Pascual JM. Syndrome of the third frontal convolution: Léon Ectors´ legacy on paradoxical ipsilateral hemiparesis. Acta Neurol Belg 2024; 124:37-48. [PMID: 37815739 DOI: 10.1007/s13760-023-02394-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/21/2023] [Indexed: 10/11/2023]
Abstract
Since the crossed control of sensitive-motor body functions by the contralateral cerebral hemispheres was recognized in the early 18th century, clinicians have been baffled by patients developing a motor deficit involving the extremities on the same side as an intracranial lesion. In the first third of the 20th century, three main hypotheses were proposed to explain this so-called ipsilateral or paradoxical hemiparesis: (1) the absence of decussation of the corticospinal tracts; (2) diaschisis, or blocking of the normal input to a brain region anatomically distant from the injured site; and (3) compression of the contralateral cerebral peduncle against the tentorial border, also known as the Kernohan-Woltman notch phenomenon. Here, we deal with the less widely known contributions of the Belgian neurosurgeon Léon Ectors, who included this paradoxical deficit within a neurological syndrome he considered highly specific for an early diagnosis of those meningiomas growing over the third frontal convolution. The present manuscript includes a systematic review of the cases of ipsilateral hemiparesis secondary to intracranial masses reported in ancient and modern scientific medical literature. We also address in-depth the physiopathological theories accounting for this syndrome and contrast them with Léon Ectors' observations.
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Affiliation(s)
- Rodrigo Carrasco-Moro
- Department of Neurosurgery, Ramón y Cajal University Hospital, Colmenar Rd. Km. 9.100, 28034, Madrid, Spain.
| | | | - María Pérez-Pérez
- Department of Neurosurgery, Ramón y Cajal University Hospital, Colmenar Rd. Km. 9.100, 28034, Madrid, Spain
| | - José María Pascual
- Department of Neurosurgery, La Princesa University Hospital, Madrid, Spain
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Roy D, Chakravarty A. The Kinetics of Transtentorial Brain Herniation: Kernohan-Woltman Notch Phenomenon Revisited. Curr Neurol Neurosci Rep 2023; 23:571-580. [PMID: 37610638 DOI: 10.1007/s11910-023-01295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE OF REVIEW To critically review recent literature in understanding the pathological consequences of transtentorial brain herniation resulting from unilateral expanding supratentorial mass lesions. RECENT FINDINGS Modern neuroimaging assists in understanding the consequences of transtentorial brain herniation with the development of the Kernohan-Woltman notch phenomenon. MRI studies in post-operative patients undergoing craniotomy and removal of expanding unilateral hemispheric mass lesions (usually an extradural or subdural hematoma) have shown striking findings in the contralateral crus cerebri suggestive of damage as a result of impact against the free margin of the opposite tentorium as suggested by Kernohan and Woltman nearly a century back in autopsy studies. MR changes include T1 hypointensity, T2 and fluid-attenuated inversion recovery (FLAIR) hyperintensity, DW1 hyperintensity with restriction of diffusion, presence of hypointensity in GRE sequences and evidence of axonal damage in the corticospinal tracts in the cerebral peduncle in diffusion tensor imaging and MR tractography. The pathological basis of such changes may be variable or a combination of several pathological processes, which may all be related to the impact/compression of the contralateral crus with the tentorial margin. These include contusion, compression, demyelination, and perhaps most importantly microvascular damage including microbleeds. The role of uncal herniation is debatable. It appears that as a result of massive lateral shift in the supratentorial compartment, there is a transient forceful impact of the opposite cerebral peduncle against the rigid tentorial border to induce one or more of the abovementioned phenomena to explain the imaging findings. The limitation of these studies is that most of them have been done in the post-operative periods and surgical manipulations can surely alter anatomical relationships between intracranial structures. The exact sequence of events happening intracranially in the face of rapidly expanding supratentorial mass lesions is largely unknown. Even with rapid progress in neuroimaging, documentation of such changes during life are difficult, principally for logistic reasons. Consequently, the very truth of the much taught about phenomenon of uncal herniation and the resultant Kernohan-Woltman notch phenomenon and the false localizing sign of unilateral motor weakness and contralateral pupillary dilation have been questioned. Animal experimentation and autopsy studies have not contributed much in our understanding of the actual process happening intracranially in such an emergent situation. The midbrain undoubtedly is the key structure bearing the brunt of the effect of brain shift which is more lateral than downward in cases with unilateral expanding lesions. Structural changes in the cerebral peduncles have now been visualized with modern neuroimaging. These alterations may result from the interplay of one or more factors which include compression, contusion, demyelination, and perhaps most importantly microvascular ischemia and hemorrhage resulting from a forceful yet transient impact of the cerebral peduncle with the tough tentorial margin. The last mentioned hypothesis would be in conformity with Kernohan and Woltman's concept of elastic deformation of the midbrain. In the present article an attempt is made to provide a historical account of the changing concepts in relation to brain herniation as systematically and chronologically as possible, and then, critically review recent neuroimaging observations with a view to hypothesize on the sequence of events during transtentorial brain herniation.
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Affiliation(s)
- Debasish Roy
- Department of Neurology, Vivekananda Institute of Medical Sciences, Kolkata, India
| | - Ambar Chakravarty
- Department of Neurology, Vivekananda Institute of Medical Sciences, Kolkata, India.
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Carrasco-Moro R, Martínez-San Millán JS, Pascual JM. Beyond uncal herniation: An updated diagnostic reappraisal of ipsilateral hemiparesis and the Kernohan-Woltman notch phenomenon. Rev Neurol (Paris) 2023; 179:844-865. [PMID: 36907707 DOI: 10.1016/j.neurol.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/23/2022] [Accepted: 11/25/2022] [Indexed: 03/12/2023]
Abstract
PURPOSE This works comprehensively analyses a modern cohort of patients with ipsilateral hemiparesis (IH) and discusses the pathophysiological theories elaborated to explain this paradoxical neurological sign according to the findings from contemporary neuroimaging and neurophysiological techniques. METHODS A descriptive analysis of the epidemiological, clinical, neuroradiological, neurophysiological, and outcome data in a series of 102 case reports of IH published on since the introduction of CT/MRI diagnostic methods (years 1977-2021) was performed. RESULTS IH mostly developed acutely (75.8%) after traumatic brain injury (50%), as a consequence of the encephalic distortions exerted by an intracranial haemorrhage eventually causing contralateral peduncle compression. Sixty-one patients developed a structural lesion involving the contralateral cerebral peduncle (SLCP) demonstrated by modern imaging tools. This SLCP showed certain variability in its morphology and topography, but it seems pathologically consistent with the lesion originally described in 1929 by Kernohan & Woltman. The study of motor evoked potentials was seldom employed for the diagnosis of IH. Most patients underwent surgical decompression, and a 69.1% experienced some improvement of the motor deficit. CONCLUSIONS Modern diagnostic methods support that most cases in the present series developed IH following the KWNP model. The SLCP is presumably the consequence of either compression or contusion of the cerebral peduncle against the tentorial border, although focal arterial ischemia may also play a contributing role. Some improvement of the motor deficit should be expected even in the presence of a SLCP, provided the axons of the CST were not completely severed.
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Affiliation(s)
- R Carrasco-Moro
- Department of Neurosurgery, Ramón y Cajal U, Comenar Rd., Km. 9.100, Madrid, Spain.
| | | | - J M Pascual
- Department of Neurosurgery, La Princesa U. H, Madrid, Spain
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Murhega RB, Balemba Ghislain M, Mudekereza PS, Musilimu S, Bisimwa I, Munguakonkwa Budema P, Mubenga L. Kernohan-Woltman notch phenomenon in patient with subdural hematoma and ipsilateral hemiparesis in Bukavu. Clin Case Rep 2023; 11:e7643. [PMID: 37415583 PMCID: PMC10319946 DOI: 10.1002/ccr3.7643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/12/2022] [Accepted: 06/23/2023] [Indexed: 07/08/2023] Open
Abstract
Key Clinical Message Kernohan-Woltman phenomenon is a rare and paradoxical neurological situation in which a transtentorial lesion leads to compression of the contralateral cerebral peduncle responsible for compression of the descending corticospinal fibers with clinical consequence of a motor deficit ipsilateral to the primary lesion. This phenomenon should attract the attention of clinicians in order to avoid unfortunate incidents such as wrong-side craniotomy in neurosurgical practice. In this work, we report a similar situation. Abstract The Kernohan-Woltman notch phenomenon is a rare and paradoxical neurological situation in which transtentorial damage is observed leading to compression of the contralateral cerebral peduncle responsible for compression of descending corticospinal fibers with the clinical consequence of a motor deficit ipsilateral to the primary lesion. This phenomenon has been found in several situations including tumors and cerebral hematomas after craniocerebral trauma. In this work, we have reported the case of a 52-year-old man with hemiparesis ipsilateral to a large chronic subdural hematoma.
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Affiliation(s)
- Roméo Bujiriri Murhega
- Department of SurgeryProvincial General Reference Hospital of BukavuBukavuDemocratic Republic of Congo
- Faculty of MedicineUniversité Catholique de BukavuBukavuDemocratic Republic of Congo
- Department of NeurosurgeryNational Hospital of NiameyNiameyNiger
| | - Maheshe Balemba Ghislain
- Department of SurgeryProvincial General Reference Hospital of BukavuBukavuDemocratic Republic of Congo
- Department of RadiologyProvincial General Reference Hospital of BukavuBukavuDemocratic Republic of Congo
| | - Paterne Safari Mudekereza
- Department of SurgeryProvincial General Reference Hospital of BukavuBukavuDemocratic Republic of Congo
- Faculty of MedicineUniversité Catholique de BukavuBukavuDemocratic Republic of Congo
| | - Sudi Musilimu
- Department of SurgeryProvincial General Reference Hospital of BukavuBukavuDemocratic Republic of Congo
- Faculty of MedicineUniversité Catholique de BukavuBukavuDemocratic Republic of Congo
| | - Igega Bisimwa
- Department of SurgeryProvincial General Reference Hospital of BukavuBukavuDemocratic Republic of Congo
- Faculty of MedicineUniversité Catholique de BukavuBukavuDemocratic Republic of Congo
| | - Paul Munguakonkwa Budema
- Department of SurgeryProvincial General Reference Hospital of BukavuBukavuDemocratic Republic of Congo
- Faculty of MedicineUniversité Catholique de BukavuBukavuDemocratic Republic of Congo
| | - Léon‐Emmanuel Mubenga
- Department of SurgeryProvincial General Reference Hospital of BukavuBukavuDemocratic Republic of Congo
- Faculty of MedicineUniversité Catholique de BukavuBukavuDemocratic Republic of Congo
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Carrasco Moro R, Pascual Garvi JM, Vior Fernández C, Espinosa Rodríguez EE, Martín Palomeque G, Cabañes Martínez L, López Gutiérrez M, Acitores Cancela A, Barrero Ruiz E, Martínez San Millán JS. Kernohan-Woltman notch phenomenon: an exceptional neurological picture? Neurologia 2022:S2173-5808(22)00173-0. [PMID: 36396093 DOI: 10.1016/j.nrleng.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Ipsilateral hemiparesis (IH) can be defined as a paradoxical dysfunction of the first motor neuron involving the extremities on the opposite side to that expected, given the location of the triggering intracranial pathology. Compression of the corticospinal tract (CSt) along its course through the contralateral cerebral peduncle against the free edge of the tentorium, known as the Kernohan-Woltman notch phenomenon (KWNP), represents the main cause of IH. METHODS This retrospective study analyses a series of 12 patients diagnosed with IH secondary to KWNP treated at our institution, including a descriptive study of epidemiological, clinical, radiological, neurophysiological, and prognostic variables. RESULTS In 75% of the cases, symptoms had an acute or subacute onset. Initial imaging studies showed signs of significant mass effect in half of the patients, whereas magnetic resonance imaging (MRI) identified a structural lesion in the contralateral cerebral peduncle in two thirds of them. Impairment of the motor evoked potentials (MEP) was verified in 4 patients. During follow-up 7 patients experienced improvement in motor activity, and near half of the cases were classified in the first three categories of the modified Rankin scale. CONCLUSIONS In contrast to prior historical series, most of our patients developed a KWNP secondary to a traumatic mechanism. MRI represents the optimal method to identify both the classic cerebral peduncle notch and the underlying structural lesion of the CSt. The use of MEP can help to establish the diagnosis, especially in those cases lacking definite radiological findings.
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Affiliation(s)
- R Carrasco Moro
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - J M Pascual Garvi
- Servicio de Neurocirugía, Hospital Universitario La Princesa, Madrid, Spain
| | - C Vior Fernández
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - G Martín Palomeque
- Servicio de Neurofisiología Clínica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - L Cabañes Martínez
- Servicio de Neurofisiología Clínica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M López Gutiérrez
- Servicio de Neurocirugía, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
| | - A Acitores Cancela
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Barrero Ruiz
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Lin Y, Chen-Lung Chou A, Lin X, Wu Z, Ju Q, Li Y, Ye Z, Zhang B. A case of Kernohan-Woltman notch phenomenon caused by an epidural hematoma: the diagnostic and prognostic value of PET/CT imaging. BMC Neurol 2022; 22:419. [DOI: 10.1186/s12883-022-02965-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Kernohan-Woltman notch phenomenon (KWNP) classically occurs when a lesion causes compression of the contralateral cerebral peduncle against the tentorium, resulting in ipsilateral hemiparesis. It has been studied clinically, radiologically and electrophysiologically which all confirmed to cause false localizing motor signs. Here, we demonstrate the potential use of fluorine-18 fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) to identify KWNP caused by an epidural hematoma.
Case presentation
A 29-year-old male patient post right-sided traumatic brain injury presenting with persistent ipsilateral hemiparesis. Patient underwent decompressive craniotomy and intracranial hematoma evacuation. Brain magnetic resonance imaging in the postoperative period showed a subtle lesion in the left cerebral peduncle. PET/CT was performed to exclude early brain tumor and explain his ipsilateral hemiparesis. PET/CT imaging demonstrated a focal region of intense 18 F-FDG uptake in the left cerebral peduncle. Throughout the treatment in outpatient neurorehabilitation unit, the patient exhibited a gradual recovery of his right hemiparesis.
Conclusion
In our case report, for the first time, PET/CT offered microstructural and functional confirmation of KWNP. Moreover, our case suggests that 18 F-FDG PET/CT may serve as an important reference for the probability of functional recovery.
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Beucler N, Cungi PJ, Baucher G, Coze S, Dagain A, Roche PH. The Kernohan-Woltman Notch Phenomenon : A Systematic Review of Clinical and Radiologic Presentation, Surgical Management, and Functional Prognosis. J Korean Neurosurg Soc 2022; 65:652-664. [PMID: 35574584 PMCID: PMC9452377 DOI: 10.3340/jkns.2022.0002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/26/2022] [Indexed: 11/27/2022] Open
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Kim HK, Baek MS, Ahn SJ, Lyoo CH. Asymmetric Parkinsonism With Progressive Nigrosomal Change Secondary to Kernohan's Notch Phenomenon. J Mov Disord 2022; 15:184-186. [PMID: 35287263 PMCID: PMC9171314 DOI: 10.14802/jmd.21162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Han-Kyeol Kim
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Seok Baek
- Department of Neurology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Jun Ahn
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chul Hyoung Lyoo
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Carrasco Moro R, Pascual JM. Some historical remarks on ipsilateral hemiparesis and the absence of decussation of the pyramidal tracts. Acta Neurochir (Wien) 2022; 164:749-50. [PMID: 34415445 DOI: 10.1007/s00701-021-04942-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
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Ciçek A, Cortier J, Hendrickx S, Van Cauwenbergh J, Calus L, Dehem J, Vanhauwaert D. Chiari Type I Malformation Presenting with Unilateral Hearing Loss. J Neurol Surg A Cent Eur Neurosurg 2021; 84:285-287. [PMID: 34100267 DOI: 10.1055/s-0041-1725959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Chiari type I malformations can present in different ways, but the most frequent symptom is an occipitocervical headache. Hearing loss as the main presenting symptom is rare. CASE A young woman with progressive left-sided unilateral hearing loss was diagnosed with a Chiari type I malformation. She underwent a suboccipital craniectomy with C1 laminectomy and duraplasty. The hearing loss had resolved postoperatively with normalization of the audiometry. CONCLUSION Chiari type I malformation can present solely with hearing loss. Improvement after surgical decompression is possible. This phenomenon is not emphasized well enough within the neurologic community. In this report, we present a summary of the pathophysiology and management in Chiari type I malformations.
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Affiliation(s)
- Abdulhamid Ciçek
- Department of Neurosurgery, AZ Delta, Roeselare, Belgium.,Department of Neurosurgery, Jan Yperman Hospital, Ypres, Belgium
| | - Jeroen Cortier
- Department of Neurosurgery, AZ Delta, Roeselare, Belgium
| | | | | | - Lien Calus
- Department of Ear, Nose and Throat Surgery, Jan Yperman Hospital, Ypres, Belgium
| | - Johan Dehem
- Department of Radiology, Jan Yperman Hospital, Ypres, Belgium
| | - Dimitri Vanhauwaert
- Department of Neurosurgery, AZ Delta, Roeselare, Belgium.,Department of Neurosurgery, Jan Yperman Hospital, Ypres, Belgium
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Abstract
This article introduces the basic concepts of intracranial physiology and pressure dynamics. It also includes discussion of signs and symptoms and examination and radiographic findings of patients with acute cerebral herniation as a result of increased as well as decreased intracranial pressure. Current best practices regarding medical and surgical treatments and approaches to management of intracranial hypertension as well as future directions are reviewed. Lastly, there is discussion of some of the implications of critical medical illness (sepsis, liver failure, and renal failure) and treatments thereof on causation or worsening of cerebral edema, intracranial hypertension, and cerebral herniation.
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Affiliation(s)
- Aleksey Tadevosyan
- Department of Neurology, Tufts University School of Medicine, Beth Israel Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | - Joshua Kornbluth
- Department of Neurology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Box#314, Boston, MA 02111, USA
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Abstract
A 24-year-old female patient was admitted for a right frontal intracranial hematoma with an uncal herniation due to a ruptured arteriovenous malformation and therefore underwent emergency surgery. Neuroimaging revealed left-sided midbrain notching against the tentorium, indicating Kernohan's notch phenomenon. She denied experiencing any short-term neurological deficits but right-sided delayed hemiparkinsonism developed 18 months later. Dopamine transporter tracer uptake was severely reduced in the left striatum, suggesting nigrostriatal degeneration secondary to Kernohan's notch. Uncal herniations are potentially fatal, but surgery can save the patient's life and improve the functional outcomes. Clinicians should therefore be aware of delayed hemiparkinsonism as a rare complication of Kernohan's notch phenomenon.
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Affiliation(s)
- Masayuki Ueda
- Department of Neurology and Stroke Medicine, Tokyo Metropolitan Tama Medical Center, Japan
| | - Marie Tsunogae
- Department of Neurology and Stroke Medicine, Tokyo Metropolitan Tama Medical Center, Japan
| | - Hiroshi Saito
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Japan
| | - Takeya Suzuki
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Japan
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Li B, Sursal T, Bowers C, Cole C, Gandhi C, Schmidt M, Mayer S, Al-Mufti F. Chameleons, red herrings, and false localizing signs in neurocritical care. Br J Neurosurg 2020; 36:298-306. [PMID: 32924623 DOI: 10.1080/02688697.2020.1820945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
False localizing signs (FLS) and other misleading neurological signs have long been an intractable aspect of neurocritical care. Because they suggest an incorrect location or etiology of the pathological lesion, they have often led to misdiagnosis and mismanagement of the patient. Here, we reviewed the existing literature to provide an updated, comprehensive descriptive review of these difficult to diagnose signs in neurocritical care. For each sign presented, we discuss the non-false localizing presentation of symptoms, the common FLS or misleading presentation, etiology/pathogenesis of the sign, and diagnosis, as well as any other clinically relevant considerations. Within cranial neuropathies, we cover cranial nerves III, IV, V, VI, VII, VIII, as well as multiple cranial nerve involvement of IX, X, and XII. FLS ophthalmologic symptoms indicate diagnostically challenging neurological deficits, and here we discuss downbeat nystagmus, ping-pong-gaze, one-and-a-half syndrome, and wall-eyed bilateral nuclear ophthalmoplegia (WEBINO). Cranial herniation syndromes are integral to any discussion of FLS and here we cover Kernohan's notch phenomenon, pseudo-Dandy Walker malformation, and uncal herniation. FLS in the spinal cord have also been relatively well documented, but in addition to compressive lesions, we also discuss newer findings in radiculopathy and disc herniation. Finally, pulmonary syndromes may sometimes be overlooked in discussions of neurological signs but are critically important to recognize and manage in neurocritical care, and here we discuss Cheyne-Stokes respiration, cluster breathing, central neurogenic hyperventilation, ataxic breathing, Ondine's curse, and hypercapnia. Though some of these signs may be rare, the framework for diagnosing and treating them must continue to evolve with our growing understanding of their etiology and varied presentations.
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Affiliation(s)
- Boyi Li
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Tolga Sursal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chad Cole
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Meic Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Stephan Mayer
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
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Yoo D, Kim HG, Bang JI, Lee KM, Ahn TB. In vivo demonstration of selective vulnerability of dopamine neurons. J Neurol Sci 2020; 415:116946. [PMID: 32521343 DOI: 10.1016/j.jns.2020.116946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/09/2020] [Accepted: 05/25/2020] [Indexed: 11/22/2022]
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Riveros Gilardi B, Muñoz López JI, Hernández Villegas AC, Garay Mora JA, Rico Rodríguez OC, Chávez Appendini R, De la Mora Malváez M, Higuera Calleja JA. Types of Cerebral Herniation and Their Imaging Features. Radiographics 2020; 39:1598-1610. [PMID: 31589570 DOI: 10.1148/rg.2019190018] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cerebral herniation, defined as a shift of cerebral tissue from its normal location into an adjacent space, is a life-threatening condition that requires prompt diagnosis. The imaging spectrum can range from subtle changes to clear displacement of brain structures. For radiologists, it is fundamental to be familiar with the different imaging findings of the various subtypes of brain herniation. Brain herniation syndromes are commonly classified on the basis of their location as intracranial and extracranial hernias. Intracranial hernias can be further divided into three types: (a) subfalcine hernia; (b) transtentorial hernia, which can be ascending or descending (lateral and central); and (c) tonsillar hernia. Brain herniation may produce brain damage, compress cranial nerves and vessels causing hemorrhage or ischemia, or obstruct the normal circulation of cerebrospinal fluid, producing hydrocephalus. Owing to its location, each type of hernia may be associated with a specific neurologic syndrome. Knowledge of the clinical manifestations ensures a focused imaging analysis. To make an accurate diagnosis, the authors suggest a six-key-point approach: comprehensive analysis of a detailed history of the patient and results of clinical examination, knowledge of anatomic landmarks, direction of mass effect, recognition of displaced structures, presence of indirect radiologic findings, and possible complications. CT and MRI are the imaging modalities of choice used for establishing a correct diagnosis and guiding therapeutic decisions. They also have important prognostic implications. The preferred imaging modality is CT: the acquisition time is shorter and it is less expensive and more widely available. Patients with brain herniation are generally in critical clinical condition. Making a prompt diagnosis is fundamental for the patient's safety.©RSNA, 2019.
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Affiliation(s)
- Berta Riveros Gilardi
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - José Ignacio Muñoz López
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Antonio Carlos Hernández Villegas
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Juan Alberto Garay Mora
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Oralia Cristina Rico Rodríguez
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Roberto Chávez Appendini
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Marianne De la Mora Malváez
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Jesús Antonio Higuera Calleja
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
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Feria AL, Akinduro OO, Rahmathulla G, Tavanaiepour D. False Localizing Trigeminal V2 Sensory Loss in Vestibular Schwannoma. Cureus 2020; 12:e9256. [PMID: 32821602 PMCID: PMC7431979 DOI: 10.7759/cureus.9256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
False localizing signs involving cranial nerves are rare, even more so when involving the trigeminal nerve. Here we present the first case of trigeminal V2 sensory loss as a false localizing sign. The sensory dysfunction was caused by a large contralateral cystic vestibular schwannoma and subsequently improved after tumor resection. The clinical and radiographic features are described, and proposed mechanisms for this false localizing sign are discussed.
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Affiliation(s)
| | | | - Gazanfar Rahmathulla
- Neurological Surgery, University of Florida College of Medicine, Jacksonville, USA
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Leever JD. Unilateral cerebral herniation resulting in combined contralateral superior cerebellar artery territory infarction and mesencephalic injury: Two cases of a severe unrecognized variant of Kernohan notch phenomenon? Radiol Case Rep 2020; 15:250-253. [PMID: 31956382 PMCID: PMC6957800 DOI: 10.1016/j.radcr.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/29/2019] [Accepted: 12/11/2019] [Indexed: 11/25/2022] Open
Abstract
A case of unilateral cerebral herniation due to an acute middle cerebral artery territory infarct and a second case of unilateral cerebral herniation due to an acute subdural hematoma are presented in this article. In both instances, the unilateral cerebral herniation resulted in a combined contralateral superior cerebellar artery territory infarction and mesencephalic injury. Unilateral cerebral herniation resulting in a combined contralateral superior cerebellar artery territory infarct and mesencephalic injury is previously undescribed in the literature and likely reflects a severe unrecognized variant of Kernohan notch phenomenon.
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Ten Harmsen BL, De Kleermaeker FGCM, de Leeuw C, van Dijk G. Neuro-images Kernohan-Woltman notch phenomenon in acute subdural hematoma. Acta Neurol Belg 2020; 120:189-190. [PMID: 31912445 DOI: 10.1007/s13760-019-01270-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 12/28/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Bibet L Ten Harmsen
- Department of Neurology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Floriaan G C M De Kleermaeker
- Department of Neurology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands.
- Department of Neurology, VieCuri Medisch Centrum, Tegelseweg 210, 5912 BL, Venlo, The Netherlands.
| | - Carola de Leeuw
- Department of Neurology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Gert van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
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Carrasco-Moro R, Castro-Dufourny I, Martínez-San Millán JS, Cabañes-Martínez L, Pascual JM. Ipsilateral hemiparesis: the forgotten history of this paradoxical neurological sign. Neurosurg Focus 2019; 47:E7. [DOI: 10.3171/2019.6.focus19337] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/12/2019] [Indexed: 11/06/2022]
Abstract
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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Affiliation(s)
| | - Ines Castro-Dufourny
- 2Department of Endocrinology, Sureste University Hospital, Francisco de Vitoria University
| | | | | | - José M. Pascual
- 5Department of Neurosurgery, La Princesa University Hospital, Madrid, Spain
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