Critical Care >Principles of Neurosciences Critical Care

John M. Oropello, Stephen M. Pastores, Vladimir Kvetan+

Table 48A–1OHerniation syndromes.

Herniation Syndrome Level of arousal Motor Exam Pupillary Exam Other Findings

Subfalcine, early Drowsy to lethargy Normal to CL LE paresis, paratonia Normal

Subfalcine, late Stupor to coma CL LE paresis, FP CL >IL Small, minimally reactive

Diencephalon shift, early Drowsy to lethargy Possible CL HP, paratonic Small, minimally reactive

Diencephalon shift, late Stupor to coma FP CL >IL to QP Mid-position, NR, maybe irregular

Uncal, early Lethargy to stupor Localizes IP, paratonic CL IP Mydriasis, NRa

IP eye is abducted and depressed

Uncal, late Stupor to coma CL FP/EP to HP (IP ~ 25%) IP Mydriasis, NR
w/ptosisa

Central (transtentorial), diencephalon

Lethargy to stupor Localizes to withdrawal Small, minimally reactive
stage

DC gaze w/impaired adduction on

Central (transtentorial), midbrain stage Coma FP to EP Mid-position, NR, maybe irregular
VOR

Central (transtentorial), pontine stage Coma QP, ± TF of LEs Miotic No VOR

Central (transtentorial), medullary

Coma QP, ± TF of LEs Miotic or Mydriatic and NR Hypotension and apnea
stage

Tonsillar Coma QP, ± TF of LEs Miotic Hypotension and apnea

Upward, early Lethargy Quadraparesis to QP Mid-position, NR, maybe irregular Impaired upward gaze

Upward, late Coma EP to QP, ± TF of LEs Mid-position, NR, maybe irregular No VOR

CL, contralateral; IL, ipsilateral; UE, upper extremity; LE, lower extremity; QP, quadriplegia; NR, nonreactive; VOR, oculocephalic testing; TF, triple flexion; FP, flexor posturing; EP, extensor posturing; HP,
hemiparesis; DC, dysconjugate.

aDue to the anatomic location of the third cranial nerve (CN3), the first finding in uncal herniation can be a partial to full CN3 palsy.

Date of download: 02/02/23 from AccessMedicine: accessmedicine.mhmedical.com, Copyright © McGraw Hill. All rights reserved.