Brain herniations in patients with intracerebral hemorrhage

To study the types, frequency and clinical correlates of brain herniations in patients with intracerebral hemorrhage (ICH). In 24 patients with ICH (putaminal 22 and thalamic 2) features of raised intracranial pressure (ICP), such as hyperventilation, extensor rigidity, pupillary asymmetry and pyramidal signs on the non-hemiplegic side, were recorded.

Depth of coma was assessed by using the Glasgow Coma Scale (GCS) and severity of stroke by using the Canadian Neurological Scale (CNS). On MRI, evidence of herniation, horizontal and vertical shifts and the edema-hematoma complex were measured and compared with that of 15 matched controls. The clinical signs of herniation correlated with radiological parameters.

The mean age of the patients was 57.7 years, six of them were women. Cerebral herniations were present in 11 (46%) patients. Subfalcian herniation (in six) was the commonest followed by uncal (in three). Combination of subfalcian and uncal herniations was present in one and subfalcian, uncal and tonsillar herniations in another.

Herniations had significant correlation with the GCS, pupillary abnormalities, cortical atrophy, hematoma size and the edema-hematoma complex. One-month mortality was related to the GCS score, pupillary abnormalities and the edema-hematoma complex. Horizontal shift was related to the GCS score. In patients with ganglionic ICH, subfalcian herniation was the commonest.

Herniation was associated with increased mortality. Horizontal shift correlated with clinical features of raised ICP and outcome.