Reversible uncal herniation in a neonate with a large MCA infarct
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Published on: April 21, 2017
Ronald L Thibert1, Joseph D Burns, Rafeeque Bhadelia
1Pediatric Epilepsy Program, Massachusetts General Hospital, Boston, MA, USA.
Abstract:
Uncal herniation due to a large cerebral infarct is well-described in adults, with high rates of morbidity and mortality. This phenomenon, however, has not been previously reported in neonates. We present a newborn male delivered via cesarean section with difficult extraction who presented with frequent seizures. He was found to have an acute left MCA territory infarct secondary to an M1 occlusion detected on MRI/MRA. He became lethargic and developed a left uncal herniation on CT at 72h of life. He was treated medically with osmolar agents and hemodynamic support, and had resolution of the herniation on CT at 120h of life. At 19 months he had residual moderate right hemiparesis with only mild gait disturbance and mild speech delay. As seen in this case, uncal herniation, though rare, may occur in neonates. Also, the outcome for this neonate was much better than for typical adults with a similar disease course.
Insights
Uncal herniation, a rare complication of large cerebral infarcts, is reported for the first time in neonates. This newborn experienced a stroke and uncal herniation but showed a better outcome than adults.
Area of Science:
- Neurology
- Neonatology
- Pediatric Neurology
Background:
- Uncal herniation secondary to large cerebral infarcts is a known complication in adults, associated with significant morbidity and mortality.
- This phenomenon has not been previously documented in the neonatal population.
Observation:
- A newborn male presented with seizures following a difficult cesarean delivery.
- Neuroimaging revealed an acute left middle cerebral artery (MCA) territory infarct due to M1 occlusion.
- The infant subsequently developed lethargy and left uncal herniation, confirmed by CT scan.
Findings:
- Medical management with osmolar agents and hemodynamic support led to the resolution of uncal herniation within 48 hours.
- At 19 months, the patient exhibited moderate right hemiparesis, mild gait disturbance, and mild speech delay.
Implications:
- This case demonstrates that uncal herniation can occur in neonates following large cerebral infarcts.
- The neonatal outcome in this case was more favorable compared to typical adult presentations with similar pathology.
- Highlights the need for vigilance and potential for different clinical trajectories in neonatal cerebrovascular events.
