HERNIATION OF THE

BRAIN
HERNIATION OF THE BRAIN
• Changes in shape and position that occur from intracranial mass
lesions
• Cranial cavity is a closed space and cannot accommodate changes in
intracranial volume
• presence of a supratentorial or posterior fossa mass increases intracranial
pressure
• With further expansion, this causes herniation of the brain
Uncal Herniation
• resulted from a subdural hematoma
• In the lower right of the figure, the
uncus of the temporal lobe is shown
herniating around the tentorium
cerebelli, with compression of the
posterior cerebral artery (PCA) (lower
arrow) and third cranial nerve (CN III).
• The upper half of the figure shows
subfalcine herniation with brain
herniating under the falx cerebri and
compression of the anterior cerebral
artery (ACA) (upper arrow).
Uncal Herniation
• occurs when unilateral and expanding supratentorial lesions (esp in
the middle cranial fossa) shift the mediobasal edge of the uncus of
the hippocampal gyrus toward the midline and over the free edge of
the tentorium → compressing the adjacent midbrain
• Cranial nerve III and occasionally the posterior cerebral artery on the
side of the herniating temporal lobe are compressed by the
overhanging swollen uncus.
Uncal Herniation: Clinical Signs
• Cranial nerve III - ipsilateral palsy of cranial nerve III, usually
beginning with dilatation of the
• Contralateral cerebral peduncle against the free edge of the
tentorium - hemiparesis and the Babinski sign ipsilateral to the
expanding lesion.
• Midbrain - affects the ascending reticular activating system, causing
progressive loss of consciousness.
• Posterior cerebral artery - infarction of the occipital lobe producing
homonymous hemianopia.
Central or Transtentorial Herniation
• Further progression of uncal herniation
• Associated with parasagittal or bilateral supratentorial masses
• Consists of caudal displacement of the diencephalon, midbrain, and
pons
• Blocks the flow of cerebrospinal fluid through the aqueduct of Sylvius,
further increasing the volume of the supratentorial contents. \
• Because mass lesions are rarely directly in the midline, some degree
of lateral shift and uncal herniation nearly always accompanies
transtentorial herniation.
Central or Transtentorial Herniation:
Clinical Signs

• Oculomotor paresis
• Progressive alteration of consciousness
• Decerebrate posturing
Central or Transtentorial Herniation
Duret hemorrhages
• Caudal displacement of the basilar
artery (which is attached to the
circle of Willis by the posterior
cerebral arteries) does not occur to
the same degree, resulting in
stretching and shearing of
paramedian perforating vessels,
with secondary infarction and
hemorrhage in the brainstem
Subfalcine Herniation
• expanding mass in the supratentorial area may result in herniation of
the cingulate gyrus under the falx cerebri
• If the herniation is significant, the mass can compress the anterior
cerebral artery and result in infarction.
Subfalcine Herniation: Clinical Signs
• contralateral leg weakness
• increased somnolence (increase sleepiness)
Tonsillar or Foramen Magnum Herniation
• As a result of an expanding mass in the posterior fossa or further
progression of uncal or transtentorial herniation, the cerebellar tonsils
herniate downward through the foramen magnum and compress the
medulla
Tonsillar or Foramen Magnum
Herniation:
Clinical Signs
• Neck pain and stiffness, the result of stretching and irritation of the
lower cranial nerves supplying the neck muscles
• Progressive loss of consciousness from involvement of the ascending
reticular activating system
• Generalized flaccidity
• Alteration of vital signs, with slowing of the pulse and vasomotor
instability
• Periodic or irregular respirations from involvement of visceral centers
in the medulla
Cerebellar Tonsillar Herniation
• Due to Posterior fossa
hemorrhage
• Downward cerebellar tonsillar
herniation (arrow) through the
foramen magnum