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Original article

Surgical management of persistent post-traumatic trans-tentorial

brain hernia
Prise en charge chirurgicale de la hernie cérébrale trans-tentorielle
post-traumatique persistante
A. Scibilia ∗ , P. Gallinaro , J. Todeschi , S. Chibbaro , G. Dannhoff , I. Ollivier , M.T. Bozzi ,
M. Ganau , F. Proust , H. Cebula
Division of Neurosurgery, University of Strasbourg, 1, avenue Molière, 67200 Strasbourg, France

a r t i c l e i n f o a b s t r a c t

Article history: Introduction. – Temporal engagement may persist after etiologic surgical treatment of acute subdural
Received 23 January 2021 hematoma (ASH) without clinical improvement despite normalized intracranial pressure (ICP). The aim
Received in revised form 20 June 2021 of this study was to assess the feasibility of secondary direct temporal lobe disengagement (DTLD) after
Accepted 22 June 2021
surgery for supratentorial ASH and to evaluate clinical outcome.
Available online xxx
Materials and methods. – This was a retrospective analysis of 4 patients undergoing secondary DTLD.
Patient data were recorded at admission, pre- and postoperatively and at 6 months’ follow-up (FU): age,
Keywords:
gender, Rotterdam score, Glasgow Coma Scale (GCS), neurological deficits, oculomotor nerve palsy (ONP),
Traumatic brain injury
Trans-tentorial brain hernia
ICP, midline shift, complications and Extended Glasgow Outcome Scale (GOS-E).
Temporal lobe disengagement Results. – At postoperative evaluation 48 h after DTLD, we observed a significant improvement in GCS
Intracranial pressure score (initial 6 ± 3, preoperative 7 ± 3, postoperative 14 ± 1; P = 0.02), midline shift (initial 16 ± 3 mm,
preoperative 13 ± 5 mm, postoperative 9 ± 2 mm; P = 0.049) and ONP (P = 0.01). In all cases, early postop-
erative imaging documented visualization of a patent ipsilateral peri-mesencephalic cistern. At 6-month
FU, GOS-E showed 75% good recovery and 25% disability. Complete ONP recovery was observed in 75%
of patients (P = 0.01). Neurological deficits were present at FU in 25% of patients. No surgery-related
complications or mortality were recorded.
Conclusions. – In traumatic brain injury, secondary DTLD may allow simple, effective and safe management
of trans-tentorial uncal herniation, avoiding more challenging procedures. Clinical results are promising,
as this technique seems to favorably influence neurological outcome in this selected subgroup of patients
with persistent clinical and radiological signs of temporal engagement after etiological treatment with
normal ICP values.
© 2021 Elsevier Masson SAS. All rights reserved.

r é s u m é

Mots clés : Introduction. – L’engagement temporal peut persister après le traitement chirurgical étiologique de
Traumatisme crânien l’hématome sous-dural aigu (HSDA) sans amélioration clinique malgré la normalisation de la pression
Hernie cérébrale trans-tentorielle intracrânienne (PIC). Le but de cette étude est d’évaluer la faisabilité du désengagement secondaire direct
Désengagement du lobe temporal du lobe temporal (DSDLT) après une chirurgie pour une HSDA supratentorielle et d’évaluer les résultats
Pression intracrânienne
cliniques.

∗ Corresponding author.
E-mail address: ninoscib98@gmail.com (A. Scibilia).

https://doi.org/10.1016/j.neuchi.2021.06.012
0028-3770/© 2021 Elsevier Masson SAS. All rights reserved.

Please cite this article as: Scibilia A, et al, Surgical management of persistent post-traumatic trans-tentorial brain hernia, Neurochirurgie,
https://doi.org/10.1016/j.neuchi.2021.06.012
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Matériel et méthodes. – Il s’agit d’une analyse rétrospective de 4 patients opérés pour un DSDLT. Les
variables des patients (âge, sexe, score de Rotterdam, Glasgow Coma Scale [GCS], présence de déficits
neurologiques, paralysie du nerf oculomoteur [PNO], surveillance PIC, shift de la ligne médiane, compli-
cations et Extended Glasgow Outcome Scale [GOS-E]) ont été enregistrées à l’admission, avant et après
l’opération et au suivi à 6 mois.
Résultats. – À l’évaluation précoce des résultats (48 h après DSDLT), nous avons observé une amélioration
significative du score GCS (initial 6 ± 3, préopératoire 7 ± 3, postopératoire 14 ± 1, p = 0,02), du shift de
la ligne médiane (initial 16 ± 3 mm, préopératoire 13 ± 5 mm, postopératoire 9 ± 2 mm, p = 0,049) et de
la PNO (p = 0,01). Dans tous les patients, l’imagerie postopératoire précoce a documenté la visualisation
d’une citerne péri-mésencéphalique homolatérale perméable. À l’évaluation à six mois, les distributions
du score GOS-E étaient les suivantes : bon rétablissement 75 %, handicap sévère 25 %. Une récupération
de la PNO complète a été observée dans 75 % des patients (p = 0,01). Des déficits neurologiques étaient
présents à 6 mois dans 25 % des patients. Aucune complication et mortalité liées à la chirurgie n’ont été
enregistrées.
Conclusions. – Dans le cadre du traumatisme crânien, le DSDLT peut permettre une prise en charge
simple, efficace de la hernie uncal trans-tentorielle évitant des procédures plus difficiles. Les résultats clin-
iques sont prometteurs, car cette technique semble influencer favorablement les résultats neurologiques
de ce sous-groupe sélectionné de patients présentant des signes cliniques et radiologiques persistants
d’engagement temporel après un traitement étiologique avec des valeurs de PIC normales.
© 2021 Elsevier Masson SAS. Tous droits réservés.

1. Abbreviations supratentorial acute subdural hematoma. Furthermore, the impact

of such a technique on longitudinal patient’s clinical and radiolog-
ical outcome was investigated.
ANOVA Analysis of Variance
CT computed tomography 3. Materials and methods
CSF cerebrospinal fluid
DTLD direct temporal lobe disengagement 3.1. Study design and setting
GCS Glasgow Coma Scale
GOS-E Extended Glasgow Outcome Scale We performed a retrospective single-center study, on a prospec-
ICP intracranial pressure tive built database including patients undergoing to secondary
ICU intensive care unit DTLD after surgery for supratentorial acute subdural hematoma
IRB Institutional Review Board managed from September 2018 to September 2019 at our insti-
ONP oculomotor nerve paralysis tution.
STROBE Strengthening the Reporting of Observational Studies in
Epidemiology
3.2. Participants, variables, data sources, study size
TBI traumatic brain injury
The eligibility criteria included:
2. Introduction
• age of ≥ 18 years;
Trans-tentorial brain herniation represents a life-threatening
• surgery for acute subdural hematoma;
condition associated to high morbidity and mortality rate [1] in
• persistence of clinical and radiological signs of temporal engage-
a wide range of neurosurgical disorders especially in severe trau-
ment at 48 hours after surgery (clinical signs: stupors or comatose
matic brain injury (TBI) with supratentorial hematoma [2].
state, oculomotor nerve paralysis ONP, and persistent neurolog-
Currently, despite the modern implementation of relevant
ical impairment; radiological signs: prevalent unilateral mass
neuro-intensive care and neurosurgical treatments only 26% of
effect with dislocation of the midbrain and obliteration of the
patients with acute subdural hematoma reach a favorable outcome
peri-mesencephalic cisterns on computed tomography CT scan);
[Extended Glasgow Outcome Scale (GOS-E) 4 and 5] [3]. In this
• absence of high (> 25 mmHg) intracranial pressure (ICP).
setting, trans-tentorial herniation with temporal engagement con-
stitutes an independent prognostic predictor of poor outcome with
merely 15% of patients achieving a favorable outcome and with a Exclusion criteria were as follow:
high overall mortality rate of 70% [4].
Moreover, temporal engagement may persist after etiologic sur- • the presence of irreversible brainstem disorders signs (i.e., Duret
gical management of acute subdural hematoma with absence of hemorrhage);
clinical improvement despite the decrease of intracranial pressure. • severe hemodynamic impairment;
In the TBI scenario, different surgical techniques have been • persistence of hemorrhagic diathesis at the time of clinical eval-
proposed with the aim to treat uncal brain herniation with sev- uation despite reversion attempt.
eral indications and applications, such as temporal lobectomy
[5–7], selective unco-parahippocampectomy [8,9] and cisternos- We recorded demographic and preoperative clinical informa-
tomy [1,10,11]. tion (Fig. 1) including age, sex, intracranial pathology, Rotterdam
The purpose of this study was of assessing the feasibility and CT score [12]. Clinical and radiological data [Glasgow Coma Scale
efficacy of a simpler and less invasive surgical technique such as (GCS), presence of neurological motor and language deficits, ONP,
the secondary direct temporal lobe disengagement (DTLD), to solve midline shift in mm] were assessed at the time of admission and
out a persistent trans-tentorial brain herniation after surgery for before surgery for temporal disengagement (Fig. 1).

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Fig. 1. Demographic, Clinical Characteristics of Patients, Results of Surgery and Follow-up Data. R: right; L: left; ASDH: acute subdural hematoma; GCS: Glasgow Coma Scale;
ONP: oculomotor nerve palsy; GOS-E: Glasgow Outcome Scale Extended; DTLD: direct temporal lobe disengagement; ICP: intracranial pressure; NE: not evaluable.

As previously defined [13,14], ONP was considered as complete

if all the following criteria were found: ptosis, unreactive mydri-
asis, and ophthalmoplegia (we did not considered diplopia, not
explorable in comatose patients); incomplete if one or more of
these items were absent. Complete ONP restoration was defined
as the absence of all of the above criteria (including postoperative
diplopia) and incomplete if one or more of the listed items were
present [13,14].

3.3. Initial surgical and intensive care management

All patients underwent to standard evacuation of acute subdural

hematoma through a standard large traumatic skin/bone flap.
All 4 patients had an intraparenchymal ICP monitoring device
(Camino® , Integra). Neuromonitoring data were recorded at 1 h
intervals and the mean ICP values was calculated for 48 hours after
surgery. All patients were treated according to the current interna-
tional guidelines [15]. They were sedated, mechanically ventilated Fig. 2. Schematic drawing representing the direct temporal disengagement tech-
in intensive care unit (ICU) and cerebral perfusion pressure was nique. Coronal view. A brain retractor is positioned sub-temporally and gradually
deepened. The herniated uncus is gently retracted and elevated back. Abundant irri-
maintained between 60 and 70 mmHg.
gation by warm saline solution into an infero-mesial direction is performed in order
Forty-eight hours after surgery, in cases of persistence of clinical of freeing the peri-mesencephalic cistern.
and radiological signs of trans-tentorial herniation despite means
ICP values ≤ 25 mmHg, a “secondary” DTLD was performed.

3.4. Surgical technique 3.5. Outcome analysis

The patient is positioned supine with the head turned 45◦ to the
opposite side. The previous “question mark point” trauma flap is
utilized and, if necessary, extended more caudally to widely expose
the temporal fossa area. The previous fronto-temporo-parietal
bone flap is taken out and, if necessary, the temporal squama fur-
ther rougeured off to reach the floor of the temporal fossa. Once the
dura mater is opened, under microscopic magnification, after pro-
tecting the brain surface by patties, a brain retractor is positioned
sub-temporally and gradually deepened until exposing the tento-
rial notch very anteriorly. The herniated uncus is gently retracted
and elevated back to its natural position in a backwards way. Fur-
thermore, an abundant irrigation by warm saline solution into an
infero-mesial direction is performed in order of freeing the peri-
mesencephalic cistern allowing to reestablish the cerebrospinal
fluid (CSF) circulation between the infra- and supratentorial com-
partments, indicating that the brainstem has been decompressed
(Fig. 2).
Forty-eight hours after DTLD, early postoperative outcome was
clinically evaluated by means of GCS score, the presence of neuro-
logical deficits and ONP. Furthermore, early (48 hours) radiological
outcome was analysed by CT scan analyzing the patency of ipsilat-
eral peri-mesencephalic cisterns along with reduction of midbrain
displacement. Midline shift (mm) was also assessed as surrogate
radiological endpoint.
Long-term outcome was assessed at 6 months, through outpa-
tient clinic evaluation, by recording the GOS-E, the presence of
permanent neurological deficits and ONP. GOS-E distributions were
collected and the resulting clinical outcome was stratified as “favor-
able” GOS-E ≥ 5 and “unfavorable” GOS-E < 5 [11].
Predicted outcome was calculated with TBI IMPACT score
(Core + CT + Lab model) [16] for each patient and compared with
observed outcome (GOS-E).
Complications such as neurovascular injuries, iatrogenic brain
contusions, postsurgical hematomas were recorded [11].

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3.6. Statistical methods
For all preoperative, surgical, and outcome variables, percent-
ages of frequency distributions were analyzed. Analysis of Variance
(ANOVA) test was used for longitudinal analysis of the GCS score,
ONP and midline shift. For this purpose, ONP categorical data
were transformed into continuous data. Statistical significance was
defined as a P-value < 0.05. Data analysis was performed using
GraphPad Prism version 6.00 for Windows (GraphPad Software, La
Jolla, California, http://www.graphpad.com/).
3.7. Ethics
This study was conducted according to the Ethical Principles for
Medical Research Involving Human subjects stated in the 2004 and
its further revision made in 2008 and 2013 of the Declaration of
Helsinki. To report our results, we followed the recommendations
of the STROBE (Strengthening the Reporting of Observational Stud-
ies in Epidemiology) statement for observational studies [17]. The
study was approved by the Institutional Review Board (IRB) of the
French National Neurosurgery society (reference No.: IRB00011687
IRB #1: 2020/21).
All patients signed an informed consent for the scientific use of
data at follow-up examination according to the IRB.
4. Results
4.1. Participants, descriptive and outcome data
In the selected timeframe, among patients operated for post-
traumatic subdural hematoma at our Institution (n = 56), a total of
4 patients (7%) were included in this study.
Among them, 3 were men and 1 woman with a mean age of
58.2 ± 11.6 years, (ranging from 47 to 71 years). They were affected
by isolated traumatic brain injury and the etiology were road acci-
dent for two patients and fall with TBI for the other two patients. At
the time of TBI, only 1 of them assumed oral anticoagulant therapy
(vitamin K antagonist) for atrial fibrillation that was reversed dur-
ing the first surgery (for subdural hematoma). The other 3 patients
did not present significant comorbidities that could have interfered
with their outcome. Clinical patient’s data are summarized in Fig. 1.
During 48 hours after subdural hematoma evacuation, all
patients presented normal ICP values (Fig. 1). All patients
underwent secondary DTLD after post-traumatic acute subdural
hematoma surgery.
The early postoperative outcome (48 hours after DTLD) revealed
a significant improvement in GCS score being initially 6 ± 3, preop-
eratively 7 ± 3, postoperatively 14 ± 1, (P = 0.02, Fig. 3A).
Longitudinal ONP analysis revealed a significant (P = 0.01)
improvement at the early and long-term outcome as reported in
Fig. 3B.
Accordingly, longitudinal analysis of neurological deficit
unveiled an improvement in early and long-term outcome (initial
and preoperative: 100% of patients with neurological deficit, early
outcome 50% of patients; long-term outcome 25% of patients).
At follow-up evaluation, GOS-E distributions were as follows:
good recovery 75%, severe disability 25%. The patient who evolved
toward a severe disability presented bilateral temporal lobe contu-
sions.
The comparison between predicted and observed outcome is
outlined in Table 1.
The initial radiological exploration revealed a mean Rotterdam
CT score of 5 ± 1. The early radiological outcome analysis revealed
a significant improvement of midline shift (initial 16 ± 3 mm, pre-
operative 13 ± 5 mm, postoperative 9 ± 2 mm, P = 0.049, Fig. 3C). In
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all cases, the early postoperative CT scan documented an effec-
tive disengagement of the temporal lobe by the visualization of
an ipsilateral patent peri-mesencephalic cistern (Fig. 4).
None of patients presented clinical or radiological signs of pos-
terior cerebral artery ischemia. We did not observe either early or
late surgery-related complications or deaths.
5. Discussion
5.1. Key results
In this retrospective single-center study, we reported the pre-
liminary results of a secondary DTLD in patients with persistence
of oculomotor nerve and brainstem compression after etiological
management despite the normalization of ICP. The combination of
gentle traction and irrigation allowed to obtain surgical treatment
of brain trans-tentorial herniation without parenchymal sacrifice.
The perioperative findings were corroborated by early postoper-
ative radiological analysis showing midbrain decompression and
good visualization of ipsilateral peri-mesencephalic cistern.
Notably, the implementation of this surgical technique enabled
the achievement of encouraging early and long-term clinical
outcome associated to ONP recovery. No surgery-related complica-
tions were recorded. The only patient presenting a severe disability
suffered of bilateral temporal lobe contusions.
5.2. Rationale, interpretation and literature review
The physiopathology of trans-tentorial herniation has been
extensively reported; it leads to compression of the posterior cir-
culation arteries, and particularly the small midbrain perforating
branches, and finally to hemorrhagic (i.e., Duret’s hemorrhages)
and ischemic (i.e., posterior cerebral artery ischemia) compli-
cations [4]. Moreover, the herniated uncus can squeeze and
straighten the oculomotor nerve or compress the midbran and
Edinger–Westphal nuclei. The resulting clinical herniation syn-
drome includes anisocoria (with initial homolateral pupillary
dilation and loss of photomotor reflex), consciousness impairment
and asymmetric motor response (usually, contralateral hemipare-
sis) [4].
In the setting of severe TBI, sometimes, simply evacuation of a
supratentorial hematoma and maximal neuro-intensive treatment
may not relieve clinical herniation syndrome, especially in the early
postsurgical period.
Actually, prolonged temporal engagement with ICP increase
may create irremediable ischemic of hemorrhagic injury to the
deep cerebral and brainstem structures, leading to permanent mor-
bidity and mortality in up to 70% of cases [2,4,18]. In patients with
elevated ICP values, secondary decompressive craniectomy is indi-
cated [15,19].
However, persistence of clinical signs of trans-tentorial her-
niation after etiological treatment, with normal ICP values and
radiological absence of ischemic or hemorrhagic midbrain damage,
may suggest a sub-acute midbrain impairment whose potential
for recovery could remain preserved. We may postulate differ-
ent mechanisms as “functional midbrain distress” and impartment
of CSF circulation between the infra- and supratentorial compart-
ments due to peri-mesencephalic cisterns compression.
For these reasons, in this subset of patients, after 48 hours of
maximal neuro-intensive treatment, we decided to perform sec-
ondary DTLD without decompressive craniectomy with the aim to
promote and optimize early recovery of brain, brainstem and oculo-
motor nerve. Moreover, we hypothesized that prompt restoration
of basal cisternal circulation could have also prevented CSF dynamic
delayed complications.
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Fig. 3. A. Longitudinal analysis of Glasgow Coma Scale (GCS) score demonstrating significant improvement of mean GCS score after DTLT (48 h). B. Longitudinal analysis of
oculomotor nerve palsy (ONP) demonstrating significant improvement of ONP outcome after DTLT at the early stage (48 h) and follow-up (6 months) evaluation. C. Longitudinal
analysis of midline shift demonstrating decreasing of midline shift after DTLT. DTLT: direct temporal lobe disengagement.

Table 1
Comparison between predicted outcome (calculated with TBI IMPACT score) and observed outcome.

Patient TBI impact TBI impact Observed outcome

Predicted outcome Predicted outcome GOS-E (6 months)
(probability of 6 months (probability of 6 months
mortality) unfavourable outcome)

Patient 1 68% 92% 8 (favourable outcome)

Patient 2 47% 70% 7 (favourable outcome)
Patient 3 39% 63% 4 (unfavourable outcome)
Patient 4 42% 65% 8 (favourable outcome)

TBI: traumatic brain injury.

In the microsurgical era, other surgical treatments of trans-
tentorial herniation have been proposed, essentially temporal
lobectomy, selective unco-parahippocampectomy and cisternos-
tomy [5–9,11]. Table 2 summarizes the surgical techniques,
indications and postoperative outcomes of the most relevant
reports [5–9,11] focused on treatment of trans-tentorial hernia-
tion.
Based on our preliminary results, the DTLD, proposed in the
present study in selected patients, presents some advantages.
It seems to be a straightforward and more expeditious surgical
technique, to perform as an emergency, being also effective in opti-
mizing patient recovery, reducing length of ICU stay, morbidity and
mortality. The promotion of early good patient recovery seems to
be a key result. Moreover, the comparison between the predicted
(TBI IMPACT score) and observed (GOS-E) outcome at 6 months
highlights the favorable impact of DTLD technique on patients’
outcome.
In regards to complications, although a favorable tendency has
been observed, the absence of significant surgery-related compli-
cations may be attributable to the few number of patients studied.
The theoretical disadvantage of such a technique could be
considered the lack of subpial visual control of midbrain and neu-
rovascular structures as oculomotor nerve and posterior cerebral
artery although the latter seems easily to be overcame thanking
our choice of subtemporal approach starting very anteriorly and,
once the tentorial notch is identified, going gently backwards. Fur-
thermore, it is a matter of fact that a significant advantage in this
subgroup of patients is the absence of intracranial hypertension
with limited brain swelling and temporal lobe distortion that pecu-
liarly minimize the brain retraction favoring the identification of
anatomical structures.
Finally, we propose such a technique as a life-saving procedure
by directly decompressing the brainstem, relieving the pressure
gradient and in this way reversing acute and/or progressive neuro-
logical deterioration due to downward trans-tentorial herniation.
We are wondering if such a technique should be performed pri-
marily as we believe that if implemented in the first instance, and
combined with state-of-the-art of ICU management, it may remark-
ably improve the mortality and morbidity rates associated with
trans-tentorial herniation.

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Table 2
Published studies examining different techniques for trans-tentorial herniation treatment and outcomes.

Study Number of Surgical Indication Primary or Favourable Unfavourable Mortality rate

patients technique secondary outcome outcome (≥ 6 months)
(GOS-E ≥ 5) (GOS-E < 5)

Nussbaum et al., 1991 10 Temporal Unilateral hemispheric Primary 70% 30% 30%
lobectomy swelling without significant

ARTICLE IN PRESS
hematoma
Litofsky et al., 1994 20 Lobectomies Adjuvant TBI treatment in Secondary 55% 45% 35%
(15% temporal) patients who subsequently
deteriorate or develop elevated
ICP
Mori et al., 1998 13 Selective unco- Progressive trans-tentorial Secondary 27% 73% 15%
parahippocampectomy herniation caused by different
acute supratentorial mass
lesions (only 23% TBI)
Chibbaro et al., 2008 80 Decompressive Severe TBI patients acute Secondary 75% 25% 15%
craniectomy and/or progressive clinical
6

and selective signs of elevated ICP with

unco- trans-tentorial herniation
parahippocampectomy
Hakan et al., 2019 10 Decompression Severe TBI patients Primary 60% 40% 40%
surgery and
temporal
lobectomy
Giammatei et al., 2020 18 Cisternostomy Primary: predominantly Primary and 61% 39% 22%
and unilateral mass effect secondary
decompressive Secondary: all patients who
craniectomy had refractory ICP despite
medical management
Present Study 4 Direct Persistent trans-tentorial Secondary 75% 25% 0%
temporal herniation after acute
disengagement intracranial hematoma surgical
treatment in presence of
normal ICP values

TBI: traumatic brain injury; GOS-E: Glasgow Outcome Scale Extended; ICP: intracranial pressure.

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Fig. 4. Case 2. Fifty years old female patient presented a traumatic brain injury after a vasovagal episode. The Glasgow Coma Scale (GCS) evaluation on admission was 3 with
anisocoria right > left and presence of corneal reflex. The initial CT scan (A) demonstrated the presence of a voluminous right subdural hematoma associated with a temporal
engagement. An urgent surgery for hematoma evacuation was accomplished. In the postoperative period the neurological examination at temporary sedation withdrawal
revealed a GCS score of 5T (E1 VT M3) with persistence of right pupil dilatation but with intracranial pressure (ICP) values < 25 mmHg. The 48 h postoperative CT scan (B)
revealed the persistence of trans-tentorial uncal herniation and the patient benefited for a direct temporal lobe disengagement (DTLT) surgery. After DTLT, we assisted to a
clinical improvement allowing a rapid extubation and a GCS score of 15 at the early postoperative clinical evaluation with persistence of a slight right mydriasis without other
neurological deficits. CT scan (C) after DTLT (48 h) allowed visualization of peri-mesencephalic cisterns (white arrow). The 6 months clinical evaluation revealed a Glasgow
Outcome Scale Extended (GOS-E) of 7 and the complete regression of oculomotor nerve palsy (ONP).

5.3. Limitations of the study Ethics approval

The present study we believe has few limits as follow: Reference No.: IRB00011687.

• it carries intrinsic limitations related to the retrospective obser-

Consent for publication
vational design, which is associated with several methodological
drawbacks common to retrospective data;
All patients signed an informed consent for the scientific use of
• because of the small number of patients, the results, although
data at follow-up examination according to the IRB.
encouraging, should be taken with caution; thus, further prospec-
tive multicenter clinical studies with larger patient cohorts are
required to validate these findings. Authors’ contributions

6. Conclusions
In the setting of severe TBI, the secondary DTLD allows an effec-
tive and safe treatment of trans-tentorial uncal brain herniation in
a simpler way without any complex uncal microsurgical resection.
The clinical promising results showed in this preliminary study sug-
gest that this technique may favorably influence the neurological
outcome in selected patients with persistent clinical and radiolog-
ical signs of temporal engagement after etiological treatment with
normal ICP values. Finally, the idea of performing such a technique
as a primary procedure constitutes an interesting study hypothesis
that we believe deserves a further exploration and consideration.
Funding
None.
Disclosure of interest
The authors declare that they have no competing interest.
All authors have made substantial contributions to: (1) the con-
ception and design of the study, or acquisition of data, or analysis
and interpretation of data, (2) drafting the article or revising it crit-
ically for important intellectual content, (3) final approval of the
version to be submitted.
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