Kernohan-Woltman Notch Phenomenon ­ Case Report

The Kernohan-Woltman notch phenomenon is a paradoxical neurological manifestation consisting of a motor deficit ipsilateral to a primary brain injury. It has been observed in patients with brain tumors and with supratentorial hematomas. It is considered a false localizing neurological sign. Magnetic resonance imaging (MRI) scan has been the test of choice. The recognition of this phenomenon is important to prevent a surgical procedure on the opposite side of the lesion. The present case report describes a case of chronic subdural hematoma with a probable finding of the Kernohan-Woltman phenomenon, and it discusses its pathophysiology, imaging findings, treatment, and prognosis.

Intraoperative reversal of transtentorial herniation with traumatic brain injury: Clinical experience / 第二军医大学学报

A preliminary study on the intraoperative reversal of transtentorial herniation with traumatic brain injury Abstract objective To explore the advantages of the directive reversal of transtentorial herniation without incising tentorium of cerebellum in the operation on traumatic brain injury. Methods One hundred eighty-four cases of traumatic brain injuries with transtentorial herniation were collected. All the cases were operated by transfrontal-temporal-parietal approach. The cerebral hemorrhage and the focuses of contusion and laceration were cleared thoroughly. Additionally, a group of 68 cases of transtentorial herniation were reversed directly under microscope, keeping the tentorium of cerebellum contact in the surgery. The computed tomography appearance, the improvement of mind and mydriasis, intracranial pressure and surgical complications such as brain infarction, hydrocephalus were compared between the two group postoperatively. Results The statistic result indicates that the computed tomography appearances, the improvement of mind and mydriasis, intracranial pressure and surgical complications of the group of intraoperative reversal is superior to the group of non-reversal. Conclusion The directive reversal of transtentorial herniation without incising tentorium of cerebellum in the operation on traumatic brain injury is superior to the control group. Keywords Traumatic brain injury; transtentorial herniation; operation; reserval appearance, the improvement of mind and mydriasis, intracranial pressure and surgical complications such as brain infarction, hydrocephalus were compared between the two group postoperatively. Results The statistic result indicates that the computed tomography appearances, the improvement of mind and mydriasis, intracranial pressure and surgical complications of the group of intraoperative reversal is superior to the group of non-reversal. Conclusion The directive reversal of transtentorial herniation without incising tentorium of cerebellum in the operation on traumatic brain injury is superior to the control group.

Pontine Hemorrhage after Surgical Evacuation of Nontraumatic Subdural Hematoma

Duret hemorrhage is characterized by an upper brainstem hemorrhage due to increased intracranial pressure by mass effect such as subdural hematoma or a brain tumor. The anteroposterior elongation and downward displacement of the upper brainstem by transtentorial herniation results in the compression and tearing of the paramedian perforating vessels that feed the upper brainstem tegmentum. The consequent hemorrhage that involves the upper brainstem renders recovery to be almost impossible. Following a tricuspid valve replacement surgery, a 56-year-old woman developed a left fronto-temporo-parietal nontraumatic subdural hematoma resulting in transtentorial herniation of the left mesial temporal lobe. A successful surgical evacuation of the hematoma was done with clinical improvement. Two days later, she was referred to neurology with an aggravated right side weakness, dysarthria, and a newly developed extraocular movement disturbance. A brain CT and MRI showed a pontine hemorrhage. We report a case of pontine hemorrhage, a Duret hemorrhage, after the surgical evacuation of nontraumatic subdural hematoma.

Certain Considerations of the Persistant Vegetative State

Patients with overwhelming demage to the cerebral hemispheres commonly pass into a chronic state of unconsciounsness(ie, loss of self awareness) called the vegetative state. When such cognitive loss lasts for more then a few weeks, the condition has been termed a persistent vegetative state. The auther reviewed "Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state patient" adopted by the Executive Board, American Academy of Neurology, April 21, 1988 and "Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association" - 1989. In the U.S.A. they insist :If the patient is competent to act in his own befalf and did not previously indicate his preferences, the family or other surrogate decision maker, in concert with the physician, must act in the best interest of the patient" and "Even if death is not imminent but a patient is beyond doubt permanently unconscious, and there are adequate safeguards to confirm the accuracy of the diagnosis, it is not unethical to discontinue all means of life-prolonging medical treatment." In Korea :brain death" has not been referred to the death of the individual yet socially and legally. The neurosurgeons in our country must consider about how seriously to treat vegetative patients and brain death patients who are unlikly to improve, in the concerns of bio-medical ethice. On the other hand, they recognize that their capacity to achieve a diagnosis and highly probable prognosis represents the indispensable basis for any decision. This article provides criteria for the diagnosis of persistent vegetative state and reviews the available data of my 19 patients. Lastly in our country any considerations or discussions have not yet been made with regard to withdrawal of life support to patients in persistent vegetative states according to the national emotion and morality.

Experimential Brain Stem Compression

Patterns of brain-stem compression and secondary brain-stem evoked postentials were investigated to correlate with expanding mass volume and location in mass-induced supratentorial brain compression in cats in which the subjects were divided into four experimental group i.e., frontal, temporal, parietal, and occipital brain-compressed groups. Postmortem insepection of the brain-stem showed either unilateral or bilateral dorsal herniation of the brain in frontal and temporal brain-compressed groups and dorsolateral herniation in parietal and occipital brain-compressed groups, respectively. Microscopic examination revealed that the secondary brain-stem hemorrhages were mostly caused by venous bleeding secondary to venous congestion, the bleeding being more severe in occipital brain-compressed group. As the intracranial pressure was raised by expansion of a supratentorial balloon, the late components of the BSEP were suppressed first, followed by the suppression of the early components. In BSEP recording a significant change was observed in Vth wave with prolongation of latency and decrease in amplitude. This finding suggests that the midbrain is the most vulnerable to compression ischemia. In parietal group, the Vth wave started to be prolonged at 0.4ml of balloon expansion and totally disappeared at 1.8ml of expansion.