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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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Sohn J, Jung IY, Ku Y, Kim Y. Machine-Learning-Based Rehabilitation Prognosis Prediction in Patients with Ischemic Stroke Using Brainstem Auditory Evoked Potential. Diagnostics (Basel) 2021; 11:diagnostics11040673. [PMID: 33918008 PMCID: PMC8068377 DOI: 10.3390/diagnostics11040673] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 03/29/2021] [Accepted: 04/07/2021] [Indexed: 01/17/2023] Open
Abstract
To evaluate the feasibility of brainstem auditory evoked potential (BAEP) for rehabilitation prognosis prediction in patients with ischemic stroke, 181 patients were tested using the Korean version of the modified Barthel index (K-MBI) at admission (basal K-MBI) and discharge (follow-up K-MBI). The BAEP measurements were performed within two weeks of admission on average. The criterion between favorable and unfavorable outcomes was defined as a K-MBI score of 75 at discharge, which was the boundary between moderate and mild dependence in daily living activities. The changes in the K-MBI scores (discharge-admission) were analyzed by nonlinear regression models, including the artificial neural network (ANN) and support vector machine (SVM), with the basal K-MBI score, age, and interpeak latencies (IPLs) of the BAEP (waves I, I-III, and III-V). When including the BAEP features, the correlations of the ANN and SVM regression models increased to 0.70 and 0.64, respectively. In the outcome prediction, the ANN model with the basal K-MBI score, age, and BAEP IPLs exhibited a sensitivity of 92% and specificity of 90%. Our results suggest that the BAEP IPLs used with the basal K-MBI score and age can play an adjunctive role in the prediction of patient rehabilitation prognoses.
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Affiliation(s)
- Jangjay Sohn
- Interdisciplinary Program in Bioengineering, Graduate School, Seoul National University, Seoul 03080, Korea;
| | - Il-Young Jung
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Daejeon 35015, Korea;
| | - Yunseo Ku
- Department of Biomedical Engineering, Chungnam National University College of Medicine, Daejeon 35015, Korea
- Correspondence: (Y.K.); (Y.K.); Tel.: +82-42-280-8613 (Y.K.); +82-44-995-4760 (Y.K.)
| | - Yeongwook Kim
- Department of Rehabilitation Medicine, Chungnam National University College of Medicine, Daejeon 35015, Korea;
- Correspondence: (Y.K.); (Y.K.); Tel.: +82-42-280-8613 (Y.K.); +82-44-995-4760 (Y.K.)
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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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Ho KM, Honeybul S, Ambati R. Prognostic Significance of Magnetic Resonance Imaging in Patients with Severe Nonpenetrating Traumatic Brain Injury Requiring Decompressive Craniectomy. World Neurosurg 2018; 112:277-283. [PMID: 29421447 DOI: 10.1016/j.wneu.2018.01.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Diffuse axonal injury (DAI) detected on magnetic resonance imaging (MRI) may be useful to predict outcome after traumatic brain injury (TBI). METHODS This study compared the ability of the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) prognostic model with DAI on MRI to predict the 18-month neurologic outcome in 56 patients who had required decompressive craniectomy after TBI. RESULTS Of the 56 patients included in the study (19 scans occurred within 14 days; median time for all patients 24 days, interquartile range 14-42), 18 (32%) had evidence of DAI on the MRI scans. The presence of DAI on the MRI diffusion-weighted (DW) T2*-weighted gradient echo and susceptibility-weighted (SWI) sequences was associated with an increased risk of unfavorable outcome at 18 months compared with patients without DAI (44% vs. 17%, difference = 27%, 95% confidence interval 2.4-46.7%; P = 0.032), particularly when the brainstem was involved. However, neither the grading (I to IV) nor the number of brain regions with DAI was as good as the IMPACT model in discriminating between patients with unfavorable and favorable outcomes (area under the receiver operating characteristic curve: 0.625 and 0.621 vs. 0.918, respectively; P < 0.001 for both comparisons). After adjustment for the IMPACT prognostic risks, DAI in different brain regions and the grading of DAI were also not independently associated with unfavorable outcome. CONCLUSIONS The prognostic significance of DAI on MRI may, in part, be captured by the IMPACT prognostic model. More research is needed before MRI should be routinely used to prognosticate the outcomes in patients with TBI requiring decompressive craniectomy.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia; School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia.
| | - Stephen Honeybul
- Department of Neurosurgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ravi Ambati
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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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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Rollnik JD. May clinical neurophysiology help to predict the recovery of neurological early rehabilitation patients? BMC Neurol 2015; 15:239. [PMID: 26589284 PMCID: PMC4654832 DOI: 10.1186/s12883-015-0496-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/16/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND So far, the role of clinical neurophysiology in the prediction of outcome from neurological and neurosurgical early rehabilitation is unclear. METHODS Clinical and neurophysiological data of a large sample of 803 early rehabilitation cases of the BDH-Clinic Hessisch Oldendorf in Northern Germany have been carefully reviewed. Most patients (43.5%) were transferred to rehabilitation after stroke, mean age was 66.6 (15.5) years. Median somatosensory (SEP), auditory (AEP) and visual evoked potentials (VEP) along with EEG recordings took place within the first two weeks after admission. Length of stay (LOS) in early rehabilitation was 38.3 (37.2) days. RESULTS Absence of SEP on one or both sides was associated with poor outcome, χ2 = 12.98 (p = 0.005); only 12.5% had a good outcome (defined as Barthel index, BI ≥50) when SEP were missing on both sides. In AEP, significantly longer bilateral latencies III were observed in the poor outcome group (p < 0.05). Flash VEP showed that patients in the poor outcome group had a significantly longer latency III on both sides (p < 0.05). The longer latency III, the smaller BI changes (BI discharge minus admission) were observed (latency III right r = -0.145, p < 0.01; left r = -0.206, p < 0.001). While about half of the patients with alpha EEG activity belonged to the good outcome group (80/159, 50.3%), only 39/125 (31.2%) with theta and 5/41 (12.2%) with delta rhythm had a favourable outcome, χ2 = 24.2, p < 0.001. CONCLUSIONS Results from this study suggest that loss of median SEP, prolongation of wave III in AEP and flash-VEP as well as theta or delta rhythms in EEG are associated with poor outcome from neurological early rehabilitation. Further studies on this topic are strongly encouraged.
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Affiliation(s)
- Jens D Rollnik
- Institute for Neurorehabilitation Research ("InFo"), BDH Clinic Hessisch Oldendorf, Hannover Medical School (MHH), Greitstr. 18-28, 31840, Hessisch Oldendorf, Germany.
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Frassanito P, Markogiannakis G, Di Bonaventura R, Massimi L, Tamburrini G, Caldarelli M. Descending transtentorial herniation, a rare complication of the treatment of trapped fourth ventricle: case report. J Neurosurg Pediatr 2015. [PMID: 26207666 DOI: 10.3171/2015.3.peds14619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Descending transtentorial herniation (DTH) is a complication of raised pressure in the supratentorial compartment, usually resulting from mass lesion of several etiologies. The authors report an exceptional case of DTH complicating the implant of a CSF shunting device in the trapped fourth ventricle of a 17-year-old boy in whom a second CSF shunting device had been implanted for neonatal posthemorrhagic and postinfectious hydrocephalus. The insidious clinical and radiological presentation of DTH, mimicking a malfunction of the supratentorial shunt, is documented. Ultimately, the treatment consisted of removal of the infratentorial shunt and endoscopic acqueductoplasty with stenting. The absence of supratentorial mass lesion and other described etiologies of DTH prompted the authors to speculate on the hydrodynamic pathogenesis of DTH in the present case.
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Affiliation(s)
- Paolo Frassanito
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy; and
| | | | - Rina Di Bonaventura
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy; and
| | - Luca Massimi
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy; and
| | | | - Massimo Caldarelli
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy; and
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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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