Surgical management of persistent post-traumatic trans-tentorial brain hernia

Temporal engagement may persist after etiologic surgical treatment of acute subdural hematoma (ASH) without clinical improvement despite normalized intracranial pressure (ICP). The aim of this study was to assess the feasibility of secondary direct temporal lobe disengagement (DTLD) after surgery for supratentorial ASH and to evaluate clinical outcome.

This was a retrospective analysis of 4 patients undergoing secondary DTLD. Patient data were recorded at admission, pre- and postoperatively and at 6months' follow-up (FU): age, gender, Rotterdam score, Glasgow Coma Scale (GCS), neurological deficits, oculomotor nerve palsy (ONP), ICP, midline shift, complications and Extended Glasgow Outcome Scale (GOS-E).

At postoperative evaluation 48h after DTLD, we observed a significant improvement in GCS score (initial 6±3, preoperative 7±3, postoperative 14±1; P=0.02), midline shift (initial 16±3mm, preoperative 13±5mm, postoperative 9±2mm; P=0.049) and ONP (P=0.01). In all cases, early postoperative imaging documented visualization of a patent ipsilateral peri-mesencephalic cistern. At 6-month FU, GOS-E showed 75% good recovery and 25% disability. Complete ONP recovery was observed in 75% of patients (P=0.01). Neurological deficits were present at FU in 25% of patients. No surgery-related complications or mortality were recorded.

In traumatic brain injury, secondary DTLD may allow simple, effective and safe management of trans-tentorial uncal herniation, avoiding more challenging procedures. Clinical results are promising, as this technique seems to favorably influence neurological outcome in this selected subgroup of patients with persistent clinical and radiological signs of temporal engagement after etiological treatment with normal ICP values.