FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 314:953-958 April 10, 1986 Number 15 Next

	Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

Abstract

Brain-tissue shifts associated with drowsiness, stupor, and coma were studied by clinical examination and CT scanning in 24 patients with acute unilateral cerebral masses. Studies were performed soon after the appearance of the mass to detect the earliest CT changes associated with depression of consciousness. Contrary to traditional concepts, early depression of the level of alertness corresponded to distortion of the brain by horizontal displacement rather than transtentorial herniation with brain-stem compression. Horizontal displacement of the pineal body of 0 to 3 mm from the midline was associated with alertness, 3 to 4 mm with drowsiness, 6 to 8.5 mm with stupor, and 8 to 13 mm with coma. Moreover, drowsy or stuporous patients and some comatose patients had widened cisterns between the tentorial edge and the midbrain on the side of the mass, suggesting that the space was not filled by herniated medial temporal lobe. Downward displacement of the pineal body, indicating central transtentorial herniation, did not occur. Compression of one hemisphere by the other anteriorly (transfalcial herniation) was inconsistently related to alertness, though very large anterior displacements may have caused stupor in some patients. Current concepts of the pathoanatomical nature of depressed consciousness, based on pathological material obtained well after clinical examinations, may require revision, because they do not reflect early brain-tissue distortions.

This article has been cited by other articles:

• Diedler, J., Sykora, M., Blatow, M., Juttler, E., Unterberg, A., Hacke, W. (2009). Decompressive Surgery for Severe Brain Edema. J Intensive Care Med 24: 168-178 [Abstract]  
• Okauchi, M., Hua, Y., Keep, R. F., Morgenstern, L. B., Xi, G. (2009). Effects of Deferoxamine on Intracerebral Hemorrhage-Induced Brain Injury in Aged Rats. Stroke 40: 1858-1863 [Abstract] [Full Text]  
• Wijdicks, E F M (2009). Acute brainstem displacement without uncal herniation and posterior cerebral artery injury. BMJ Case Reports 2009: bcr2007126227-bcr2007126227 [Full Text]  
• Zubkov, A. Y., Wijdicks, E. F.M., Stevens, R. D., Koenig, M. A. (2009). Reversal of transtentorial herniation with hypertonic saline. Neurology 72: 200-201 [Full Text]  
• Wijdicks, E F M (2008). Acute brainstem displacement without uncal herniation and posterior cerebral artery injury. J. Neurol. Neurosurg. Psychiatry 79: 744-744 [Full Text]  
• Qureshi, A. I., Suarez, J. I. (2008). More evidence supporting a "brain code" protocol for reversal of transtentorial herniation. Neurology 70: 990-991 [Full Text]  
• (2006). October 24 Highlight and Commentary: Cerebral herniation months after decompressive craniotomy: How can this be?. Neurology 67: 1323-1323 [Full Text]  
• Pearce, J M S (2006). James Collier (1870-1935) and uncal herniation. J. Neurol. Neurosurg. Psychiatry 77: 883-884 [Full Text]  
• Chang, Y., Chen, T.-Y., Chen, C.-H., Crain, B. J., Toung, T. J. K., Bhardwaj, A. (2006). Plasma arginine-vasopressin following experimental stroke: effect of osmotherapy. J. Appl. Physiol. 100: 1445-1451 [Abstract] [Full Text]  
• Tang, S.-C., Huang, S.-J., Jeng, J.-S., Yip, P.-K. (2006). Third Ventricle Midline Shift Due to Spontaneous Supratentorial Intracerebral Hemorrhage Evaluated by Transcranial Color-Coded Sonography. J Ultrasound Med 25: 203-209 [Abstract] [Full Text]  
• Maramattom, B. V., Wijdicks, E. F. M. (2005). Uncal Herniation. Arch Neurol 62: 1932-1935 [Full Text]  
• Gootjes, E. C., Wijdicks, E. F. M., McClelland, R. L. (2005). Postoperative Stupor and Coma. Mayo Clin Proc. 80: 350-354 [Abstract]  
• Manno, E. M., Nichols, D. A., Fulgham, J. R., Wijdicks, E. F. M. (2003). Computed Tomographic Determinants of Neurologic Deterioration in Patients With Large Middle Cerebral Artery Infarctions. Mayo Clin Proc. 78: 156-160 [Abstract]  
• Inao, S, Kawai, T, Kabeya, R, Sugimoto, T, Yamamoto, M, Hata, N, Isobe, T, Yoshida, J (2001). Relation between brain displacement and local cerebral blood flow in patients with chronic subdural haematoma. J. Neurol. Neurosurg. Psychiatry 71: 741-746 [Abstract] [Full Text]  
• Steiner, T., Pilz, J., Schellinger, P., Wirtz, R., Friederichs, V., Aschoff, A., Hacke, W. (2001). Multimodal Online Monitoring in Middle Cerebral Artery Territory Stroke. Stroke 32: 2500-2506 [Abstract] [Full Text]  
• Bateman, D. E (2001). NEUROLOGICAL ASSESSMENT OF COMA. J. Neurol. Neurosurg. Psychiatry 71: i13-i17 [Full Text]  
• Kasner, S. E., Demchuk, A. M., Berrouschot, J., Schmutzhard, E., Harms, L., Verro, P., Chalela, J. A., Abbur, R., McGrade, H., Christou, I., Krieger, D. W. (2001). Predictors of Fatal Brain Edema in Massive Hemispheric Ischemic Stroke. Stroke 32: 2117-2123 [Abstract] [Full Text]  
• Gerriets, T., Stolz, E., Konig, S., Babacan, S., Fiss, I., Jauss, M., Kaps, M. (2001). Sonographic Monitoring of Midline Shift in Space-Occupying Stroke : An Early Outcome Predictor. Stroke 32: 442-447 [Abstract] [Full Text]  
• Paczynski, R. P., Venkatesan, R., Diringer, M. N., He, Y. Y., Hsu, C. Y., Lin, W., Chan, P. H. (2000). Effects of Fluid Management on Edema Volume and Midline Shift in a Rat Model of Ischemic Stroke Editorial Comment. Stroke 31: 1702-1708 [Abstract] [Full Text]  
• Stolz, E., Gerriets, T., Fiss, I., Babacan, S. S., Seidel, G., Kaps, M. (1999). Comparison of Transcranial Color-Coded Duplex Sonography and Cranial CT Measurements for Determining Third Ventricle Midline Shift in Space-Occupying Stroke. Am. J. Neuroradiol. 20: 1567-1571 [Abstract] [Full Text]  
• Zazulia, A. R., Diringer, M. N., Derdeyn, C. P., Powers, W. J. (1999). Progression of Mass Effect After Intracerebral Hemorrhage. Stroke 30: 1167-1173 [Abstract] [Full Text]  
• Wijdicks, E. F. M., Miller, G. M. (1999). Transient locked-in syndrome after uncal herniation. Neurology 52: 1296-1296 [Full Text]  
• Gerriets, T., Stolz, E., Modrau, B., Fiss, I., Seidel, G., Kaps, M. (1999). Sonographic monitoring of midline shift in hemispheric infarctions. Neurology 52: 45-45 [Abstract] [Full Text]  
• Paczynski, R. P., He, Y. Y., Diringer, M. N., Hsu, C. Y. (1997). Multiple-Dose Mannitol Reduces Brain Water Content in a Rat Model of Cortical Infarction. Stroke 28: 1437-1444 [Abstract] [Full Text]  
• Alexandrov, A. V., Pullicino, P. M., Meslin, E. M., Norris, J. W. (1996). Agreement on Disease-Specific Criteria for Do-Not-Resuscitate Orders in Acute Stroke. Stroke 27: 232-237 [Abstract] [Full Text]  
• Anderson, D. C., Bundlie, S., Larson, D. A., Rockswold, G., Mastri, A. (1988). Delayed Traumatic Midbrain Syrinx: Clinical, Pathologic, and Electrophysiologic Features. Arch Neurol 45: 221-225 [Abstract]