Silent killer presenting as isolated oculomotor nerve palsy

Head trauma can result trivial to life threatening manifestations to a person. Subdural hemotomais characterised by accumulation of blood in subdural space, in most cases it is a serious condition and requires prompt diagnosis and treatment for the same to provide good outcome. Large collection, mid line shift, brain herniation associated with subdural hematoma is associated with increased morbidity and mortality. However, if the collection is minimal or is places like tentorium cerebelli may not have the typical presentation and if it抯 picked up using the subtle signs the devastating sequelae can be prevented. We report a 19 years old male with head trauma presenting with features of right-side isolated oculomotor nerve palsy who eventually found to have tentorial subdural hemotoma in imaging which has been intervened and complications were avoided.

Individual variation of tentorial notch morphometry in a series of neurocritical patients / Variación individual de la morfometría de la hendidura tentorial en una serie de pacientes neurocríticos

Background: Cadaveric studies on humans have shown anatomical variabilities in the morphometric characteristics of the tentorial notch. These anatomical variations could influence the worsening of neurocritical patients. Objectives: 1) To investigate the morphometric characteristics of the tentorial notch in neurocritical patients using computed tomography (CT); 2) To investigate the correlation between tentorial notch measurements by CT and by magnetic resonance imaging (MRI); and 3) To analyze the individual variability of the tentorial notch anatomy seen in neurocritical patients. Methods: Prospective series of neurocritical patients was examined. An imaging protocol for measurements was designed for CT and MRI. The level of the agreement of the measurements from CT and MR images was established. According to the measurements found, patients were divided into different types of tentorial notch. Results: We studied 34 neurocritical patients by CT and MRI. Measurements of the tentorial notch via CT and MRI showed significant agreement: concordance correlation coefficient of 0.96 for notch length and 0.85 for maximum width of tentorial notch. Classification of tentorial notch measurements according to the criteria established by Adler and Milhorat, we found the following: 15 patients (58%) corresponded to a "short" subtype; 7 (21%) to "small"; 3 (9%) to "narrow"; 2 (6%) to "wide"; 2 (6%) to "large"; 1 (3%) to "long"; and 4 (12%) to "typical". Conclusions: The anatomical variability of the tentorial notch could be detected in vivo by means of CT scan and MRI. Good agreement between the measurements made using these two imaging methods was found.

Antecedentes: Estudios cadavéricos en humanos han mostrado variabilidad anatómica en las características morfométricas de la hendidura tentorial (HT). Estas variaciones anatómicas podrían influir en el neurodeterioro agudo de los pacientes neurocríticos. Objetivos: 1) Investigar las características morfométricas de la HT en pacientes neurocríticos mediante tomografía computarizada (TC); 2) Investigar la correlación de las mediciones de la HT realizadas por TC y resonancia magnética (RM); 3) Analizar la variabilidad individual de la anatomía de la HT observada en pacientes neurocríticos. Métodos: Se examinó una serie prospectiva de pacientes neurocríticos. Se diseñó un protocolo de imágenes para mediciones por TC y RM. Se estableció la concordancia de las mediciones realizadas mediante TC y RM. Según las mediciones encontradas, los pacientes se dividieron en diferentes tipos de HT. Resultados: Estudiamos 34 pacientes neurocríticos por TC y RM. Las mediciones de la HT por TC y RM mostraron una concordancia significativa: coeficiente de correlación de concordancia de 0,96 para la longitud de la HT y 0,85 para el ancho máximo de la HT. Clasificando las medidas de la HT de acuerdo con los criterios establecidos por Adler y Milhorat, encontramos: 15 pacientes (58%) correspondieron al subtipo "corto", 7 (21%) al "pequeño", 3 (9%) al "estrecho" ", 2 (6%) a "ancho ", 2 (6%) al "grande ", 1 (3%) al "largo" y 4 (12%) al "típico". Conclusiones: Se pudo detectar variabilidad anatómica de la HT in vivo, mediante TC y RM. Se encontró una buena concordancia en las medidas obtenidas con ambos métodos imagenológicos.

Study of external cerebral herniation at different times in traumatic brain injury patients after decompressive craniectomy / 中国基层医药

Objective To explore external cerebral herniation at different times in traumatic brain injury patients after decompressive craniectomy.Methods Clinical data of 90 patients with traumatic brain injury routine hemicraniectomy were analyzed,brain incisional hernia incidence and severity in early (less than a week after surgery), medium (after 7d-30d)and late (after 1 month-June),and compare GCS score and GOS score of different periods were observed.Results Brain incisional hernia incidence in early,middle and late was 42.22%,21.11%,12.12%with significant difference(χ2 =4.312,P<0.05;χ2 =4.523,P<0.05;χ2 =4.543,P<0.05),and the severity in early was the most(P<0.01);GCS scores in early,mid and late was (3.22 ±0.41)points,(6.53 ±0.37)points, (12.05 ±0.84)points with significant difference(t=5.215,P<0.05;t=6.312,P<0.05;t=6.312,P<0.05);T test showed that the difference was existed between different period of patients.Conclusion Traumatic brain injury incidence and serivity in 1 week was the most;brain hernia occurs sooner in GCS score lower patients;prognosis was worse in later external cerebral herniation patients,so GCS score and incisional hernia occurrence time is important for improving prognosis of traumatic brain injur patients.

Sudden Unexpected Death caused by Olfactory Groove Meningioma: A Case Report / 대한법의학회지

Meningiomas, one of the most common neoplasms of the central nervous system, may be encountered incidentally during autopsy. Most of these tumors, however, are benign and hence, are not considered as the chief cause of death. Further, sudden unexpected death caused by meningioma is very unusual. Moreover, the diagnosis of an incidental meningioma as the cause of sudden death may sometimes be difficult. In the present report, we describe an autopsy case of a sudden, unexpected death due to a large olfactory groove meningioma accompanied by severe cerebral edema and tonsillar herniation.

Paradoxical Herniation after Decompressive Craniectomy for Acute Subdural Hematoma

Decompressive craniectomy is usually performed to relieve raised intracranial pressure(ICP) caused by various intracranial lesions. A 67-year-old man presented with acute subdural hematoma and traumatic intracerebral hematoma. The patient underwent a decompressive craniectomy. Four weeks later, the patient presented with acute neurological deterioration. Brain computed tomographic(CT) scans revealed the marked concavity of the brain at the site of the craniectomy and associated with midline shift which was reversed by cranioplasty. We report an unusual case of cerebral herniation from intracranial hypotension after decompressive craniectomy for a traumatic subdural hematoma. The cranioplasty may be helpful to prevent paradoxial cerebral herniation.

Surgical Resuscitation of a Patient with Cerebral Herniation Secondary to Massive Hemorrhage in the Basal Ganglia: Ultrasound-monitored Aspiration

The authors report a case of hyperacute, massive hemorrhage in the left basal ganglia with severe midline shift that was treated successfully by the ultrasound-monitored free hand aspiration technique. Every effort was made to shorten time until removal of considerable amount of the hematoma and minimize duration of cerebral herniation, avoiding additional irreVersible neurological deficit. A burr hole aspiration technique was preferred to standard craniotomy procedure, and any time-consuming procedures such as stereotactic frame application were abandoned. A burr hole was localized on the basis of computed tomography images simply and quickly with a ruler, and safety of the aspiration procedure was augmented by real-time ultrasound monitoring. Such minimally invasive technique relieved cerebral herniation successfully while avoiding time consumption and the morbidity of major craniotomy procedure. Early resuscitation of the patient with cerebral herniation in this case resulted in excellent recovery of the patient's neurological deficit. The patient's mentality started to improve rapidly and was clear six months after the surgery.

Clinical study on operative effect of traumatic cerebral herniation with bilateral mydriasis / 中华创伤杂志

Objective To explore the surgical effect to traumatic tentorial herniation with bilater- al mydriasis.Methods The patients were divided into three groups,ie,epidural hematoma group,a- cute diffuse brain swelling group and cerebral contusion and/or subdural hematoma group,to perform clinical outcome analysis.Half year after operation,the neurological outcome was scored according to the Glasgow Outcome Scale.Results Of all,there were three cases with good recovery,10 with moderate disability,nine with severe disability and 10 with vegetative survival but 35 deaths.The outcome was the best in epidural hemotoma group but the poorest in acute diffuse brain swelling group.Conclusions The operative effect of traumatic cerebral herniation with bilateral mydriasis is related with the type of orig- inal injury that is important for selection of operation.Patients with cerebral herniation caused by epidural hematoma should receive immediate operation that will induce better outcome.The operation is not vital for those with cerebral herniation caused by acute diffuse brain swelling.Emergent surgery can save lives of some patients with cerebral contusion and/or subdural hematoma.Rapid diagnosis,correct operation and perioperative treatment may ensure the success of surgery.