Multimedia
 | Media file 1: Nonenhanced head computed tomography (CT) scan at the level of the lateral ventricles was obtained in a 78-year-old man who presented with respiratory failure. The image demonstrates a large right frontal and temporal subdural fluid collection with hyperattenuating and hypoattenuating components consistent with an acute on chronic subdural hematoma. Subfalcine herniation, midline shift, effacement of the ipsilateral lateral ventricle, and enlargement of the contralateral occipital horn are present. |
 | Media file 2: Nonenhanced head computed tomography scan at the level of the suprasellar cistern in the same patient as in the above image. A large right frontotemporal subdural hematoma is exerting mass effect on the right frontal and temporal lobes, with resultant effacement of the suprasellar cistern and with right-sided uncal herniation. Mass effect from the subdural hematoma effaces the ipsilateral temporal horn, causing dilatation of the contralateral temporal horn. Subfalcine herniation and narrowing of the contralateral ambient and quadrigeminal plate cisterns are present. |
 | Media file 3: Nonenhanced head computed tomography (CT) scan obtained at the level of the inferior pons in the same patient as in the above 2 images. Acute-on-chronic right temporal subdural hematoma exerts mass effect on the right temporal lobe, causing ipsilateral temporal horn, with effacement and dilatation of the contralateral temporal horn. Narrowing of the contralateral ambient and quadrigeminal plate cisterns is present, with ipsilateral widening of the ambient and quadrigeminal cisterns. |
 | Media file 4: Right parasagittal gadolinium-enhanced T1-weighted magnetic resonance image in a 9-year-old girl with a history of right cerebellar astrocytoma who presented with headaches and vomiting. Heterogeneously enhancing mass is demonstrated in the right cerebellum, with compression of the adjacent brainstem and fourth ventricle. Ascending transtentorial herniation of the cerebellum is demonstrated through the incisura. Descending tonsillar herniation also is present. |
 | Media file 5: Axial gadolinium-enhanced T1-weighted magnetic resonance image obtained at the level of the midbrain in the same patient as in the above image. A heterogeneously enhancing mass is seen in the right medial anterior cerebellum, with mass effect on the right posterior lateral midbrain and fourth ventricle. The image shows enlargement of the temporal horns of both lateral ventricles as a result of obstruction by the cerebellar mass at the level of the fourth ventricle. |
 | Media file 6: Nonenhanced computed tomography (CT) scan of the brain at the level of the body of the lateral ventricles was obtained in a 37-year-old man who underwent a right frontotemporal decompression craniectomy for a large right frontal hematoma after a skiing accident. A focal hypoattenuating infarct is seen in the right frontal lobe, with an adjacent edematous brain parenchyma herniating through the right frontotemporal craniectomy defect. The patient had communicating hydrocephalus with dilatation of the lateral ventricles. |
 | Media file 7: T1-weighted sagittal magnetic resonance image through the cervical spine in a child with a history of an Arnold-Chiari I malformation. Image shows tonsillar herniation with compression of the central canal at the craniocervical junction and resultant syringohydromyelia in the visualized portion of the cervical spinal cord. |
 | Media file 8: T2-weighted sagittal magnetic resonance image through the cervical spine was obtained in the same patient as in the above image. The cerebellar tonsils are projecting inferiorly below the level of the opisthion, with compression of the central canal at the craniocervical junction. Hyperintense syringohydromyelia in the visualized portion of the cervical spinal cord is demonstrated. |
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References
Probst MA, Baraff LJ, Hoffman JR, Wolfson AB, Ourian AJ, Mower WR. Can patients with brain herniation on cranial computed tomography have a normal neurologic exam?. Acad Emerg Med. Feb 2009;16(2):145-50. [Medline].
Danzer E, Finkel RS, Rintoul NE, Bebbington MW, Schwartz ES, Zarnow DM, et al. Reversal of hindbrain herniation after maternal-fetal surgery for myelomeningocele subsequently impacts on brain stem function. Neuropediatrics. Dec 2008;39(6):359-62. [Medline].
Koenig MA, Bryan M, Lewin JL 3rd, Mirski MA, Geocadin RG, Stevens RD. Reversal of transtentorial herniation with hypertonic saline. Neurology. Mar 25 2008;70(13):1023-9. [Medline].
Leikola J, Koljonen V, Valanne L, Hukki J. The incidence of Chiari malformation in nonsyndromic, single suture craniosynostosis. Childs Nerv Syst. Dec 16 2009;[Medline].
Aquilina K, Merchant TE, Boop FA, Sanford RA. Chiari I malformation after cranial radiation therapy in childhood: a dynamic process associated with changes in clival growth. Childs Nerv Syst. Nov 2009;25(11):1429-36. [Medline].
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Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:61-2.
Kan P, Amini A, Hansen K, et al. Outcomes after decompressive craniectomy for severe traumatic brain injury in children. J Neurosurg. Nov 2006;105(5 Suppl):337-42. [Medline].
Meadows J, Kraut M, Guarnieri M, et al. Asymptomatic Chiari type I malformations identified on magnetic resonance imaging. J Neurosurg. Jun 2000;92(6):920-6. [Medline].
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Schedler P, Geary S. Kernohan's notch phenomenon: a case study. J Neurosci Nurs. Jun 2002;34(3):158-9. [Medline].
Takeuchi K, Yokoyama T, Ito J, et al. Tonsillar herniation and the cervical spine: a morphometric study of 172 patients. J Orthop Sci. Jan 2007;12(1):55-60. [Medline].
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Further Reading
Clinical guidelines
Treatment: cerebral herniation. In: Guidelines for the prehospital management of severe traumatic brain injury, second edition.
Brain Trauma Foundation - Disease Specific Society
National Highway Traffic Safety Administration - Federal Government Agency [U.S.]. 2000 (revised 2007). 8 pages. NGC:006388
Guidelines for the management of severe traumatic brain injury. Intracranial pressure thresholds.
Brain Trauma Foundation - Disease Specific Society. 2000 (revised 2007). 4 pages. NGC:005776
Clinical trials
Establishing the Physiology of Syringomyelia
Genetic Analysis of the Chiari I Malformation
The Genetics of Chiari Type I Malformation
Related eMedicine topics
Posterior Fossa Tumors
Head Trauma (Pediatrics: Cardiac Disease and Critical Care Medicine)
Head Trauma (Trauma)
Chiari Malformation
Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology
Keywords
brain herniation, Arnold-Chiari malformation, supratentorial, uncal herniation, brain displacement, mass effect, transtentorial herniation, transtentorial, tonsillar herniation, subfalcine herniation, extracranial herniation
