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    Types of Cerebral Herniation and Their Imaging Features

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    Razan Alayed
    1. Brain herniation occurs when intracranial pressure causes brain tissue to be displaced into adjacent areas through openings in the skull. There are two main types: intracranial (within the skull) and extracranial (outside the skull). 2. Intracranial herniations include subfalcine, transtentorial, and tonsillar herniations. Transtentorial herniations can be ascending or descending (lateral or central) and involve displacement of brain tissue through the tentorium cerebelli. 3. Herniations are diagnosed using clinical information, anatomical landmarks to identify displaced structures, and imaging findings like the direction of mass effect and involvement of

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    Types of Cerebral Herniation and Their Imaging Features

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    1. Brain herniation occurs when intracranial pressure causes brain tissue to be displaced into adjacent areas through openings in the skull. There are two main types: intracranial (within the skull) and extracranial (outside the skull). 2. Intracranial herniations include subfalcine, transtentorial, and tonsillar herniations. Transtentorial herniations can be ascending or descending (lateral or central) and involve displacement of brain tissue through the tentorium cerebelli. 3. Herniations are diagnosed using clinical information, anatomical landmarks to identify displaced structures, and imaging findings like the direction of mass effect and involvement of

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    1. Brain herniation occurs when intracranial pressure causes brain tissue to be displaced into adjacent areas through openings in the skull. There are two main types: intracranial (within the skull) and extracranial (outside the skull). 2. Intracranial herniations include subfalcine, transtentorial, and tonsillar herniations. Transtentorial herniations can be ascending or descending (lateral or central) and involve displacement of brain tissue through the tentorium cerebelli. 3. Herniations are diagnosed using clinical information, anatomical landmarks to identify displaced structures, and imaging findings like the direction of mass effect and involvement of

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    65 views42 pages

    Types of Cerebral Herniation and Their Imaging Features

    Uploaded by

    Razan Alayed
    1. Brain herniation occurs when intracranial pressure causes brain tissue to be displaced into adjacent areas through openings in the skull. There are two main types: intracranial (within the skull) and extracranial (outside the skull). 2. Intracranial herniations include subfalcine, transtentorial, and tonsillar herniations. Transtentorial herniations can be ascending or descending (lateral or central) and involve displacement of brain tissue through the tentorium cerebelli. 3. Herniations are diagnosed using clinical information, anatomical landmarks to identify displaced structures, and imaging findings like the direction of mass effect and involvement of

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    Types of Cerebral

    Herniation and
    Their Imaging
    Features
    Monro-Kellie hypothesis

    – the sum of volumes of the brain, CSF, and intracranial blood is constant
    – An increase in the volume of one component will result in a decrease in the
    volume of one or both of the other components
    – When there is a change in the intracranial volume that exceeds these
    compensation mechanisms, brain tissue will be displaced from one
    compartment into another
    – A decrease in ICP can also produce herniation, as in paradoxical herniation
    Brain herniation types

    – Brain herniation can be classified into two broad categories: intracranial and
    extracranial. Furthermore, intracranial hernias can be subdivided into three
    basic types: (a) subfalcine hernia; (b) transtentorial hernia, which can be
    ascending or descending (lateral and central); and (c) tonsillar herniation.
    Approach to Diagnosing brain
    Herniation Syndromes
    – Clinical Information • Displaced Structure
    Identifying the displaced structure is
    Pt history and symptoms
    necessary to classify the type of hernia.

    – Anatomic Landmarks
    • Indirect Signs
    help determine if a specific brain structure is evaluating other potentially involved
    displaced structures can provide valuable information
    by showing indirect signs of the herniation
    – Direction of Mass Effect
    • Herniation-related Complication
    establish its location and determine the
    direction of the vector force it creates. This will
    point out the brain structures that may be
    displaced or involved.
    Herniation-related Complications

    – Stroke of the anterior cerebral artery, posterior cerebral artery, or posterior


    inferior cerebellar artery occurs owing to vascular compression.
    – Hydrocephalus manifests when there is involvement of the foramen of Monro
    or aqueduct of Sylvius
    – Cranial nerves may be affected when there is involvement of the brainstem and
    basal cisterns.
    Relevant Anatomy

    – The main dural reflections are the falx cerebri and tentorium cerebelli, which
    divide the cranial cavity into right and left cerebral hemispheres and the
    posterior fossa, thus defining the supra- and infratentorial compartments
    – The midbrain and cerebral peduncles pass through the incisura. The uncus and
    hippocampus are located just superior to the medial edges of the incisura.
    – . Basal cisterns are involved in almost any hernia type, making them a key
    anatomic landmark.
    Structures at risk of compression by
    the herniated tissue.
    – The posterior cerebral arteries, anterior choroidal arteries, and basal veins of
    Rosenthal pass around the midbrain through the perimesencephalic cistern,
    close to the free edge of the tentorium.
    – The oculomotor nerve exits the midbrain anteriorly and courses medially to the
    uncus on its way to the cavernous sinus.
    Subfalcine Hernia

    – also known as midline shift or cingulate hernia, is the most common type of
    cerebral hernia.
    – It is generally caused by unilateral frontal, parietal, or temporal lobe disease
    that creates a mass effect with medial direction, pushing the ipsilateral
    cingulate gyrus down and under the falx cerebri.
    – The anterior falx, although rigid, is displaced secondary to the mass effect. On
    the other hand, the posterior falx, wider and more rigid, will resist the
    displacement. This explains why subfalcine hernias occur anteriorly.
    – The septum pellucidum deviates at the level
    of the foramen of Monro, which serves as a
    landmark for quantification of the degree of
    midline shift. This shift can be measured on
    axial images by drawing a central line at the
    level of the foramen of Monro and measuring
    the distance between this line and the
    displaced septum pellucidum.

    In subfalcine hernias, the degree of midline


    shift correlates with the prognosis; less than 5-
    mm deviation has a good prognosis, whereas a
    shift of more than 15 mm is related to a poor
    outcome
    complications

    – In more severe hernias, the displaced tissue may compress the corpus callosum and
    contralateral cingulate gyrus, as well as the ipsilateral ventricle and both foramina of
    Monro, causing dilatation of the contralateral ventricle
    – There may also be focal necrosis of the cingulate gyrus due to direct compression
    against the falx cerebri
    – Compromise of these structures manifests clinically as hypobulia, apathy, and
    indifference
    – compression of the anterior cerebral artery, specifically the pericallosal artery, with
    consequent infarction of the corresponding vascular territory (most commonly
    manifisted by contralateral leg weakness (
    Descending Transtentorial Hernia

    – Descending transtentorial hernia (DTH) is the second most common type of


    cerebral hernia. It occurs when brain tissue is displaced downward through the
    tentorial notch
    – DTH may be divided into two types: lateral (anterior and posterior) and central
    hernias.
    – In this type of hernia, the pressure caused by the crowding of tissue within the
    incisura compromises the third cranial nerve, posterior cerebral artery, and
    midbrain.
    – Hydrocephalus develops because of the compression of the cerebral aqueduct. In
    cases with severe and abrupt downward displacement of the brainstem,
    stretching and shearing of perforating branches of the basilar artery occur,
    resulting in ischemia and hemorrhage in the brainstem
    – the effect can be multiple or even extend into the cerebellar peduncles. This is
    called Duret hemorrhage; it is a late finding and portends a poor prognosis,
    usually death
    Lateral Hernia

    – Lateral hernias occur when the medial temporal lobe is displaced downward
    through the tentorium incisura. They can be divided into anterior and posterior
    hernias, depending on the portion that is displaced.
    Anterior Hernia

    – Usually, a unilateral supratentorial lesion (particularly in the middle cranial


    fossa) causes an inferior and medial mass effect that pushes the uncus over the
    free edge of the tentorium
    – It is the first event in most cases of DTH, usually followed by herniation of more
    posteriorly located brain tissue. However, the distribution and sequence of the
    DTH will also depend on certain factors, such as the location of the disease and
    the size and configuration of the incisura
    – The initial displacement of the uncus results in effacement of the suprasellar
    cistern, the earliest finding in this type of hernia. Often, that is all it effaces. As
    the herniation progresses, there is widening of the ipsilateral
    perimesencephalic cistern, with displacement and rotation of the brainstem .
    – With more advanced herniation, the midbrain and opposite cerebral peduncle
    are compressed against the tentorial edge.
    – Descending corticospinal and corticobulbar tracts may be affected above the
    medullary decussation, resulting in motor weakness on the same side as the
    lesion, known as the Kernohan notch phenomenon (false localizing sign).
    complications

    – Compression of the posterior


    cerebral artery, third cranial
    nerve, and aqueduct of Sylvius
    may result in medial temporal
    and occipital lobe infarcts,
    blown pupil, hemiparesis, and
    hydrocephalus
    Posterior Hernia

    – In patients with occipital and posterior temporal disease, the herniation of the
    medial temporal lobe occurs more posteriorly .The parahippocampal gyrus,
    behind the uncus, is displaced downward into the posterolateral part of the
    tentorial incisura. Larger posterior hernias may also include the isthmus of the
    fornical gyrus and the anterior part of the lingual gyrus.
    – This brain tissue will impinge on the lateral part of the quadrigeminal plate
    cistern and cause displacement, rotation, and compression of the brainstem.
    – It may involve the tectum at the level of the superior colliculus, resulting in
    Parinaud syndrome, which is commonly present in this type of DTH. There is
    relatively less compression of the oculomotor nerve and posterior cerebral
    artery than in other types of DTH.
    Central Hernia

    – It usually manifests along with other types of DTH. Bilateral supratentorial


    disease causing mass effect, midline masses, severe brain edema, or
    supratentorial hydrocephalus may cause this type of hernia.
    – Effacement of the perimesencephalic cisterns is the most useful and consistent
    finding.
    – Caudal displacement of the basilar artery and pineal gland, flattening of the
    pons against the clivus, and inferior and posterior displacement of the
    quadrigeminal plate are other useful indicators of this type of hernia
    complication

    – Hydrocephalus and infarction of the posterior cerebral artery territory are


    common complications .
    – Progressive central herniation can lead to oculomotor palsy, progressive
    alteration of consciousness, decerebrate posturing, coma, and eventually death
    Ascending Transtentorial Hernia

    – occurs when a mass effect, coming from the posterior cranial fossa with an
    upward direction, displaces the cerebellar vermis and hemispheres superiorly
    through the tentorial incisura.
    – It is more likely to occur when the mass originates near the incisura, like in the
    cerebellar vermis
    Tonsillar or transtentorial?

    – In the context of increased intracranial pressure, brain tissue is displaced


    toward the site that offers less resistance. When the tentorial incisura is small,
    cerebellar tissue will slide through the foramen magnum, causing tonsillar
    herniation. On the other hand, when the tentorial opening is large, upward
    herniation of the superior cerebellar vermis will occur before tonsillar
    herniation
    complications

    – As there is upward herniation of the cerebellar vermis, anterior


    displacement of the midbrain and cerebral aqueduct takes place.
    The normal concave configuration of the quadrigeminal plate
    cistern is distorted, taking on a flat or convex morphology. If the
    posterolateral aspect of the midbrain is compressed bilaterally, the
    classic “spinning top” configuration will appear .
    – Hydrocephaly may be present due to compression of the
    aqueduct.
    – Hemispheric branches of the superior cerebellar arteries, as well as
    posterior cerebral arteries, may be compressed. This causes
    ischemic infarction of the superior portion of the cerebellar
    hemispheres and occipital cerebral lobe
    – Clinically, signs of cerebellar and brainstem compression, as well as
    increased ICP, may be present
    Tonsillar Hernia

    – Tonsillar hernia is inferior displacement of the cerebellar tonsils through the


    foramen magnum into the cervical spinal canal. It may be congenital (Chiari
    spectrum) or acquired.
    – Normal tonsillar position relative to the foramen magnum varies with age
    – In the 1st decade of life, the presence of cerebellar tonsils more than 6 mm
    below the foramen magnum is considered abnormal. In the next 2 decades, the
    reference value is 5 mm; for the 4th to 8th decades, the threshold is greater
    than 4 mm; and at age 80 years or older, 3 mm is the limit
    – The McRae line is used as a
    reference for this measurement.
    It is obtained by drawing a line
    from the basion to the
    opisthion. The degree of
    tonsillar herniation is the
    perpendicular length from the
    McRae line to the tip of the
    displaced tonsil
    causes

    – The most common cause is an infratentorial mass creating a downward mass


    effect. It may also be secondary to a supratentorial mass, in which case it is
    usually associated with a DTH. It can cause severe neurologic damage followed
    by sudden respiratory arrest.
    – Visualization of tonsils extending below the foramen magnum, anterior
    brainstem displacement, and loss of CSF surrounding it are common features
    complications

    – The fourth ventricle may be compressed, producing obstructive supratentorial


    hydrocephalus .
    – Compression of the posterior inferior cerebellar artery by the herniated tonsils
    can lead to cerebellar infarcts .
    Transalar
    Hernia
    – Transalar hernia is an
    uncommon and less described
    type of hernia. It is usually
    associated with subfalcine and
    transtentorial hernias
    – Identifying anterior or posterior
    displacement of the middle
    cerebral artery is useful for
    suspecting this type of hernia
    Extracranial Hernia

    – They are most frequently caused by postsurgical and posttraumatic cranial


    defects that allow brain tissue to pass through.
    – A large craniectomy defect allows the brain to expand without constriction. If
    the defect is too small, swollen brain may herniate with a “mushroom cap”
    appearance. This can result in compression of cortical veins and lead to venous
    infarction and contusion of the brain at the craniectomy margins.
    Paradoxical hernia

    – is a rare and potentially fatal complication of decompressive craniectomy. It is a


    neurosurgical emergency.
    – Atmospheric pressure exceeding ICP at the site of the craniectomy causes a
    pressure imbalance and consequent subfalcine and/or transtentorial hernia.
    The brain tissue is displaced from the craniectomy defect .It is often triggered
    by an acute imbalance of ICP secondary to CSF drainage or lumbar puncture
    – Symptoms include a depressed level of consciousness, autonomic instability,
    signs of brainstem release, and focal neurologic deficits
    Intracranial Hypotension

    It must be suspected in patients without an intracranial mass or edema or when


    the degree of herniation is out of proportion to the degree of mass effect
    It is caused by iatrogenic or spontaneous CSF leak. The loss of CSF volume results in
    downward descent of the brain secondary to a negative pressure gradient between
    the cranial and spinal compartments
    DTH and tonsillar hernia may manifest Also, blood volume will increase to maintain
    the intracranial volume. This results in pachymeningeal hyperemia and edema,
    which can be identified at MRI as diffuse pachymeningeal enhancement

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