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Beucler N, Cungi PJ, Dagain A. Duret Brainstem Hemorrhage After Transtentorial Descending Brain Herniation: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 173:251-262.e4. [PMID: 36868404 DOI: 10.1016/j.wneu.2023.02.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Historically, the occurrence of hemorrhage in the brainstem after an episode of supratentorial intracranial hypertension was described by Henri Duret in 1878. Nevertheless, to date the eponym Duret brainstem hemorrhage (DBH) lacks systematic evidence regarding its epidemiology, pathophysiology, clinical and radiologic presentation, and outcome. METHODS We conducted a systematic literature review and meta-analysis using the Medline database from inception to 2022 looking for English-language articles concerning DBH, in accordance with the PRISMA guidelines. RESULTS The research yielded 28 articles for 32 patients (mean age, 50 years; male/female ratio, 3:1). Of patients, 41% had head trauma causing 63% of subdural hematoma, responsible for coma in 78% and mydriasis in 69%. DBH appeared on the emergency imaging in 41% and on delayed imaging in 56%. DBH was located in the midbrain in 41% of the patients, and in the upper middle pons in 56%. DBH was caused by sudden downward displacement of the upper brainstem secondary to supratentorial intracranial hypertension (91%), intracranial hypotension (6%), or mechanical traction (3%). Such downward displacement caused the rupture of basilar artery perforators. Brainstem focal symptoms (P = 0.003) and decompressive craniectomy (P = 0.164) were potential favorable prognostic factors, whereas an age >50 years showed a trend toward a poor prognosis (P = 0.0731). CONCLUSIONS Unlike its historical description, DBH appears as a focal hematoma in the upper brainstem caused by the rupture of anteromedial basilar artery perforators after sudden downward displacement of the brainstem, regardless of its cause.
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Affiliation(s)
- Nathan Beucler
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France; Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France.
| | | | - Arnaud Dagain
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France; Val-de-Grâce Military Academy, Paris, France
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Tyngkan L, Mahfouz N, Bilal S, Fatima B, Malik N. Duret Hemorrhage after Extradural Hematoma Evacuation–A Rare Entity. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1725213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractTraumatic brainstem injury can be classified as primary or secondary. Secondary brainstem hemorrhage that evolves from raised intracranial pressure (ICP) and transtentorial herniation is referred to as Duret hemorrhage. We report a 25-year-old male who underwent emergency craniotomy, with evacuation of acute epidural hematoma, and postoperatively developed fatal Duret hemorrhage. Duret hemorrhage after acute epidural hematoma (EDH) evacuation is a very rare complication and the outcome is grave in most of the cases.
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Affiliation(s)
- Lamkordor Tyngkan
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Nazia Mahfouz
- Department of Pulmonary Medicine, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Sobia Bilal
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Bazla Fatima
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Nayil Malik
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
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Edlow BL, Threlkeld ZD, Fehnel KP, Bodien YG. Recovery of Functional Independence After Traumatic Transtentorial Herniation With Duret Hemorrhages. Front Neurol 2019; 10:1077. [PMID: 31649617 PMCID: PMC6794605 DOI: 10.3389/fneur.2019.01077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023] Open
Abstract
Historically, Duret hemorrhages have conferred a devastating prognosis. However, recent case reports suggest that cognitive and functional recovery are possible after Duret hemorrhages. Here, we describe a patient who recovered consciousness, communication, and functional independence after Duret hemorrhages caused by traumatic transtentorial herniation. We performed prospective, standardized behavioral assessments, structural MRI scans and stimulus-based functional MRI (fMRI) scans during the first 2 years of recovery. The multimodal assessments revealed reintegration of neural networks mediating language and consciousness, concurrent with the reemergence of functional independence. These observations provide insights into network-based mechanisms of recovery from coma and add to a growing body of evidence indicating that Duret hemorrhages are not invariably associated with a poor prognosis.
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Affiliation(s)
- Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - Zachary D Threlkeld
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, United States
| | - Katie P Fehnel
- Department of Neurosurgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Yelena G Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
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Quintas S, Palmí Cortés I, Zapata-Wainberg G, López Ruiz R, Vivancos J. Hemorragia de Duret durante la perfusión de tratamiento fibrinolítico. Neurologia 2019; 34:340-342. [DOI: 10.1016/j.nrl.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/07/2016] [Accepted: 09/13/2016] [Indexed: 10/20/2022] Open
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Quintas S, Palmí Cortés I, Zapata-Wainberg G, López Ruiz R, Vivancos J. Duret haemorrhage during intravenous administration of thrombolytic therapy. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Matoba K, Hyodoh H, Murakami M, Saito A, Matoba T, Ishida L, Fujita E, Yamase M, Jin S. Estimating normal lung weight measurement using postmortem CT in forensic cases. Leg Med (Tokyo) 2017; 29:77-81. [DOI: 10.1016/j.legalmed.2017.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/25/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
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Nguyen HS, Doan NB, Gelsomino MJ, Shabani S, Mueller WM. Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma. Int Med Case Rep J 2016; 9:15-8. [PMID: 26869816 PMCID: PMC4734784 DOI: 10.2147/imcrj.s95809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Secondary brain stem injury is associated with transtentorial herniation, and manifests as “Duret” hemorrhages. Such an injury has been considered a terminal brain stem event with a high morbidity and mortality, sometimes discouraging continuation of care. However, there have been rare instances where patients have had reasonable recovery. We report another case, emphasizing that such an injury by itself should not deter aggressive measures, as good outcomes remain a possibility. Case presentation A 37-year-old male sustained a right subdural hematoma after a mechanical fall while intoxicated. He presented initially with a Glasgow Coma Scale 15. Three days later, he exhibited acute neurological deterioration to Glasgow Coma Scale 4, requiring intubation and mannitol. Repeat scan demonstrated enlarging right subdural hematoma with worsening shift; brain stem hemorrhage was noted at pontomesencephalic junction. Patient was immediately taken for subdural hematoma evacuation. The following day, patient was able to sluggishly follow commands in all four extremities. He had a short stay for inpatient rehabilitation and underwent autologous cranioplasty at 3 months. On examination, he was awake, alert, and oriented to self, time, and location; he exhibited dysarthric speech, right ptosis, but followed commands in all four extremities with no focal motor weakness. Conclusion In contrast to the common belief, patients suffering from a “Duret” hemorrhage can still have a good outcome. “Duret” hemorrhages may not represent a fatal injury. The finding from this paper suggests the finding of “Duret” hemorrhages on imaging should not deter aggressive measures especially in patients with lesions causing significant mass effects. Overall clinical status should drive surgical options and clinical course.
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Affiliation(s)
- Ha Son Nguyen
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ninh B Doan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael J Gelsomino
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Novel Application of Postmortem CT Angiography for Evaluation of the Intracranial Vascular Anatomy in Cadaver Heads. AJR Am J Roentgenol 2015; 205:1276-80. [DOI: 10.2214/ajr.15.14500] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Duret haemorrhage with full recovery. Acta Neurochir (Wien) 2015; 157:1337-8; discussion 1338. [PMID: 26136197 DOI: 10.1007/s00701-015-2486-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
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Martins WA, Teixeira AB, Frigeri TM, Paglioli E. Spontaneous subdural hematoma associated to Duret hemorrhage. INTERDISCIPLINARY NEUROSURGERY 2015. [DOI: 10.1016/j.inat.2014.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Inokuchi G, Yajima D, Hayakawa M, Motomura A, Chiba F, Torimitsu S, Makino Y, Iwase H. Postmortem dynamic cerebral angiography for detecting aneurysm and bleeding sites in cases of subarachnoid hemorrhage. Forensic Sci Med Pathol 2014; 10:487-95. [PMID: 25074715 DOI: 10.1007/s12024-014-9572-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2014] [Indexed: 11/28/2022]
Abstract
One of the advantages of postmortem imaging is its ability to obtain diagnostic findings in a non-destructive manner when autopsy is either difficult or may destroy forensic evidence. In recent years, efforts have been made to incorporate computed tomography (CT) based postmortem angiography into forensic pathology; however, it is not currently clear how well the modality can determine sites of bleeding in cases of subarachnoid hemorrhage. Therefore, in this study, we investigated the utility of postmortem cerebral angiography using multi-detector row CT (MDCT) by injecting a contrast medium through a catheter inserted into the internal carotid and vertebral arteries of 10 subarachnoid hemorrhage cases. While postmortem MDCT angiography (PMCTA) was capable of detecting aneurysms in a non-destructive manner, it was sometimes difficult to identify the aneurysm and bleeding sites because of a large amount of contrast medium leaking into the extravascular space. To overcome this problem, we developed the novel contrast imaging method "dynamic cerebral angiography," which involves scanning the same area multiple times while injecting contrast medium to enable real-time observation of the contrasted vasculature. Using multiphase contrast images acquired by this method, we successfully captured the moment when contrast medium leaked from the hemorrhage site. This method will be useful for identifying exact bleeding sites on PMCTA.
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Affiliation(s)
- Go Inokuchi
- Departments of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan,
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Ishizaka S, Shimizu T, Ryu N. Dramatic recovery after severe descending transtentorial herniation-induced Duret haemorrhage: A case report and review of literature. Brain Inj 2013; 28:374-7. [DOI: 10.3109/02699052.2013.864422] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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The effect on cadaver blood DNA identification by the use of targeted and whole body post-mortem computed tomography angiography. Forensic Sci Med Pathol 2013; 9:489-95. [PMID: 23832424 DOI: 10.1007/s12024-013-9467-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2013] [Indexed: 10/26/2022]
Abstract
Post-mortem computed tomography angiography (PMCTA) involves the injection of contrast agents. This could have both a dilution effect on biological fluid samples and could affect subsequent post-contrast analytical laboratory processes. We undertook a small sample study of 10 targeted and 10 whole body PMCTA cases to consider whether or not these two methods of PMCTA could affect post-PMCTA cadaver blood based DNA identification. We used standard methodology to examine DNA from blood samples obtained before and after the PMCTA procedure. We illustrate that neither of these PMCTA methods had an effect on the alleles called following short tandem repeat based DNA profiling, and therefore the ability to undertake post-PMCTA blood based DNA identification.
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Hayashi T, Hartwig S, Tsokos M, Oesterhelweg L. Postmortem multislice computed tomography (pmMSCT) imaging of hangman’s fracture. Forensic Sci Med Pathol 2013; 10:3-8. [DOI: 10.1007/s12024-013-9430-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2013] [Indexed: 11/28/2022]
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Palmiere C, Lobrinus JA, Mangin P, Grabherr S. Detection of coronary thrombosis after multi-phase postmortem CT-angiography. Leg Med (Tokyo) 2012; 15:12-8. [PMID: 22981180 DOI: 10.1016/j.legalmed.2012.08.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/06/2012] [Accepted: 08/09/2012] [Indexed: 12/29/2022]
Abstract
The aim of this study was to compare postmortem angiography-based, autopsy-based and histology-based diagnoses of acute coronary thrombosis in a series of medicolegal cases that underwent postmortem angiographies according to multiphase CT-angiography protocol. Our study included 150 medicolegal cases. All cases underwent native CT-scan, postmortem angiography, complete conventional autopsy and histological examination of the main organs and coronary arteries. In 10 out of the 150 investigated cases, postmortem angiographies revealed coronary arterial luminal filling defects and the absence of collateral vessels, suggesting acute coronary thromboses. Radiological findings were confirmed by autopsy and histological examinations in all cases. In 40 out of 150 cases, angiograms revealed complete or incomplete coronary arterial luminal filling defects and the presence of collateral vessels. Histological examinations did not reveal free-floating or non-adherent thrombi in the coronary arteries in any of these cases. Though postmortem angiography examination has not been well-established for the diagnosis of acute coronary thrombosis, luminal filling defects in coronary arteries suggesting acute thromboses can be observed through angiography and subsequently confirmed by autopsy and histological examinations.
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Affiliation(s)
- Cristian Palmiere
- University Center of Legal Medicine, Lausanne-Geneva, University Hospital of Lausanne, Rue du Bugnon 21, Lausanne, Switzerland.
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