Duret Hemorrhage

Posted Sat, 05/08/2010 - 10:02 by Norman Loberant
Images

Figure 1a. Initial CT.

Figure 1b. Initial CT.

Figure 1c. Initial CT.

Figure 2a. CT two days later after marked clinical deterioration.

Figure 2b. CT two days later after marked clinical deterioration.

Figure 2c. CT two days later after marked clinical deterioration.

Figure 2d. CT two days later after marked clinical deterioration.

Figure 2e. CT two days later after marked clinical deterioration.

Figure 2f. CT two days later after marked clinical deterioration.

Figure 2g. CT two days later after marked clinical deterioration.


Clinical History:

69-year-old man, admitted to the ICU several days after an ischemic stroke. Shortly after admission, his condition deteriorated and he developed seizures and a comatose state.


Findings:

Figure 1a,b,c. Initial CT scan of the head showed a normal-appearing brainstem and normal prepontine and suprasellar cisterns. Figure 2 a-f. After dramatic clinical downturn, unenhanced CT shows tremendous edema of the right cerebral cortex, with marked midline deviation and subfalcine herniation, transtentorial herniation with effacement of the suprasellar and prepontine cisterns, and focal hemorrhage in the pons (Duret hemorrhage). Figure 2g. Sagittal reconstruction showing the pontine hemorrhage and cisternal effacement.


Diagnosis:

Duret hemorrhage.


Discussion:

Duret hemorrhage is a delayed brainstem hemorrhage secondary to descending transtentorial herniation. Although Duret hemorrhage may result from any condition causing herniation, most reported cases have been in victims of head trauma [1,2]. Duret hemorrhages are typically located in the midline, paramedian and ventral regions of the tegmentum of the upper brainstem (mesencephalon and pons). The pathogenesis of the Duret hemorrhages is still unclear – it is believed to be the result of stretching and laceration of the perforating branches of the basilar artery due to a caudal displacement of the upper brainstem by the descending transtentorial herniation, and also due to an anterior-posterior elongation of the brainstem by side-to-side compression [1,3]. The outcome is almost universally fatal. However, in rare cases, survival with good neurologic outcome has been described as a result of aggressive medical treatment or surgical decompression that promptly resolved the transtentorial herniation [2,4].


References / Suggested Reading:

1. Parizel PM, Makkat S, Jorens PG et al. Brainstem hemorrhages in descending transtentorial herniation (Duret hemorrhage).Intensive Care Med 2002;28:85-88. 2. Kamijo Y, Kishita R, Hamanaka S, Soma K. Duret hemorrhage is not always suggestive of poor prognosis: a case of acute severe hyponatremia. Am J of Emerg Med 2005;23:908–910. 3. Alexander E, Kushner J, Six EG. Brainstem hemorrhages and increased intracranial pressure: from Duret to computed tomography. Surg Neurol 1982;17:107-110. 4. Stiver SI, Gean AD, Manley GT. Survival with good outcome after cerebral herniation and Duret hemorrhage caused by traumatic brain injury, J Neurosurgery June 2009;110:1242-1246.


Author

Edith Abramovici, Anna Chernihovski, Norman Loberant

Department of Radiology, Western Galilee Hospital, Nahariya, Israel

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Sat, 05/08/2010 - 12:31
#1
Vikram Dogra
Vikram Dogra's picture
User offline. Last seen 23 hours 11 min ago. Offline
Joined: 05/23/2007
EXcellent teaching case.

 Thank you for your submission.

 

 

Dr. Vikram Singh Dogra

Professor of Radiology, Urology & BME
Associate Chair for Education and Research.
Department of Imaging Sciences
University of Rochester School of Medicine

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