Serebral Herniasyon Sendromları Tanı ve Tedavi Yönetimi
Özet
Serebral herniasyon, kafa içi basıncın artması sonucu beyin dokusunun patolojik olarak yer değiştirmesidir ve yüksek mortalite riski taşıyan acil bir klinik tablodur. Travma, tümör, kanama veya ödem gibi nedenlerle gelişen bu durum, beyin sapı ve kraniyal sinirler üzerinde baskı oluşturarak hayati fonksiyonları bozar. Herniasyonlar, tentoryum serebelli referans alınarak supratentoryal (unkal, santral, singulat, transkalvaryal, tektal) ve infratentoryal (tonsiller, yukarı serebellar) olmak üzere iki ana grupta sınıflandırılır. Klinik seyirde pupillerde dilatasyon, bilinç kaybı, motor bozukluklar ve solunum düzensizlikleri gibi ciddi belirtiler görülür. Tanı aşamasında radyolojik bulgular ve orta hat kayması kritik öneme sahiptir. Tedavi yönetimi, Monro-Kellie doktrinine dayanarak kafa içi basıncını düşürmeye odaklanır. Bu kapsamda cerrahi olarak hematom boşaltılması veya dekompresif kraniektomi uygulanırken; medikal olarak baş elevasyonu, sedasyon, hipertonik salin, mannitol ve kontrollü hiperventilasyon gibi yöntemlere başvurulur. Erken müdahaleye rağmen, etkilenen bölgeye bağlı olarak kalıcı sekel veya ölüm riski oldukça yüksektir.
Cerebral herniation is a clinical emergency involving the pathological displacement of brain tissue due to increased intracranial pressure, carrying a high risk of mortality. This condition, caused by factors such as trauma, tumors, hemorrhage, or edema, impairs vital functions by exerting pressure on the brainstem and cranial nerves. Herniations are classified into two main categories based on the tentorium cerebelli: supratentorial (uncal, central, cingulate, transcalvarial, tectal) and infratentorial (tonsillar, upward cerebellar). The clinical course presents severe symptoms such as pupil dilation, loss of consciousness, motor deficits, and respiratory irregularities. Radiological findings and midline shift are critical during the diagnostic phase. Treatment management focuses on reducing intracranial pressure based on the Monro-Kellie doctrine. In this context, surgical interventions include hematoma evacuation or decompressive craniectomy, while medical management involves head elevation, sedation, hypertonic saline, mannitol, and controlled hyperventilation. Despite early intervention, there remains a high risk of permanent sequelae or death depending on the affected region.
Referanslar
Koenig, M. A. , Bryan, M. , Lewin III, J. L. , Mirski, M. A. , Geocadin, R. G. , & Stevens, R. D.. Reversal of transtentorial herniation with hypertonic saline. Neurology, 2008; 70(13), 1023–1029.
Gower, D. J. , Baker, A. L. , Bell, W. O. , & Ball, M. R. Contraindications to lumbar puncture as defined by computed cranial tomography. Journal of Neurology, Neurosurgery, and Psychiatry, 1987, 50(8), 1071–1074.
Marshman LA, Polkey CE, Penney CC. Unilateral fixed dilation of the pupil as a false-localizing sign with intracranial hemorrhage: case report and literature review. Neurosurgery 2001;49:1251-5.
Hanna JP, Frank JI. Automatic stepping in the pontomedullary stage of central herniation. Neurology 1995;45:985–986.
Sekula RF, Marchan EM, Baghai P, et al. Central brain herniation secondary to fulminant acute disseminated encephalomyelitis: implications for neurosurgical management. Case report. J Neurosurg 2006;105:472–474.
Shrier DA, Shibata DK, Wang HZ, et al. Central brain herniation secondary to juvenile diabetic ketoacidosis. AJNR Am J Neuroradiol 1999;20:1885–1888.
Ropper AH. Lateral displacement of the brain and level of consciousness in patients with an acute hemispheral mass. N Engl J Med 1986;314:953-8.
Johnson PL, Eckard DA, Chason DP, Brecheisen MA, Batnitzky S. Imaging of acquired cerebral herniations. Neuroimaging Clin N Am 2002;12(2):217–228.
Laine FJ, Shedden AI, Dunn MM, Ghatak NR. Acquired intracranial herniations: MR imaging findings. AJR Am J Roentgenol 1995;165(4):967–973.
Ross DA, Olsen WL, Ross AM, Andrews BT, Pitts LH. Brain shift, level of consciousness, and restoration of consciousness in patients with acute intracranial hematoma. J Neurosurg 1989;71(4):498–502.
Haddad SH, Arabi YM. Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med 2012;20:12.
Striver S. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 2009;26(6):E7.
Sinclair AG, Scoffings DJ. Imaging of the post-operative cranium. RadioGraphics 2010;30(2):461–482.
Johnson PL, Eckard DA, Chason DP, Brecheisen MA, Batnitzky S. Imaging of acquired cerebral herniations. Neuroimaging Clin N Am 2002;12(2):217–228.
Mikulis DJ, Diaz O, Egglin TK, Sanchez R. Variance of the position of the cerebellar tonsils with age: preliminary report. Radiology 1992;183(3):725–728.
Ishikawa M, Kikuchi H, Fujisawa I, Yonekawa Y. Tonsillar herniation on magnetic resonance imaging. Neurosurgery 1988;22(1 Pt 1):77–81.
Johnson PL, Eckard DA, Chason DP, Brecheisen MA, Batnitzky S. Imaging of acquired cerebral herniations. Neuroimaging Clin N Am 2002;12(2):217–228.
Cuneo RA, Caronna JJ, Pitts L, Townsend J, Winestock DP. Upward transtentorial herniation: seven cases and a literature review. Arch Neurol 1979;36(10):618–623.
Cuneo RA, Caronna JJ, Pitts L, Townsend J, Winestock DP. Upward transtentorial herniation: seven cases and a literature review. Arch Neurol 1979;36(10):618–623.
Mokri B: The Monro-Kellie hypothesis: Applications in CSF volume depletion. Neurology, 2001;56(12):1746-1748.
Jiang JY, Xu W, Li WP, Xu WH, Zhang J, Bao YH, et al: Efficacy of standard trauma craniectomy for refractory intracranial hypertension with severe traumatic brain injury: A multicenter, prospective, randomized controlled study. J Neurotrauma, 2005;22(6):623-628.
QQiu W, Guo C, Shen H, Chen K, Wen L, Huang H, Ding M, Sun L, Jiang Q, Wang W: Effects of unilateral decompressive craniectomy on patients with unilateral acute post-traumatic brain swelling after severe traumatic brain injury. Crit Care, 2009;13(6):R185.
Le Roux P, Menon DK, Citerio G, Vespa P, Bader MK, Brophy GM, et al: Consensus summary statement of the ınternational multidisciplinary consensus conference on multimodality monitoring in neurocritical care: A statement for healthcare professionals from the neurocritical care society and the european society of intensive care medicine. Intensive Care Med,2014;40(9):1189-1209.
