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Seven Cases and a Literature Review

Richard A. Cuneo, MD; John J. Caronna, MD; Lawrence Pitts, MD; Jeannette Townsend, MD; David P. Winestock, MD

Arch Neurol. 1979;36(10):618-623.

Abstract
• Seven cases of upward transtentorial herniation occurred. In each patient, coma with reactive, miotic pupils, asymmetrical or absent caloric responses, and decerebrate posture indicated brain-stem compression. In this setting, the development of unequal, then midposition, fixed pupils signaled midbrain failure from upward herniation. Vertebral angiography showed upward displacement of the superior cerebellar arteries. Results of autopsy confirmed the existence of grooving of the vermis by the tentorial margins and, in one case, of anterior displacement and distortion of the midbrain. In five of 45 reported cases of upward herniation, the conditions were diagnosed antemortem. Instances of cerebellar hematoma and tumor predominated. In at least seven patients, performance of ventriculography may have precipitated herniation. Clinical details were provided in only nine patients and did not separate upward herniation from brain-stem compression. Cerebellar ischemic infarct found in one of our patients is a rarely reported cause of upward herniation.

Author Affiliations
From the Departments of Neurology (Drs Cuneo and Caronna), Neurological Surgery (Dr Pitts), Neuropathology (Dr Townsend), and Neuroradiology (Dr Winestock), the University of California Medical Center, San Francisco.

Footnotes
Accepted for publication Nov 13, 1978.

Presented at the 29th annual meeting of the American Academy of Neurology, Atlanta, April 30, 1977.

Reprint requests to Neurology Service 4M60, San Francisco General Hospital, San Francisco, CA 94110 (Dr Caronna).

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