Subfalcine Herniation: Causes, Symptoms, Diagnosis, and Treatment

Introduction

Subfalcine herniation is a life-threatening condition that occurs within the brain, involving the displacement of brain tissue from its usual position. This condition can have severe consequences, such as increased intracranial pressure and potential damage to vital brain structures. This article will delve into the causes, symptoms, diagnosis, and treatment options for subfalcine herniation, providing a comprehensive understanding of this critical neurological issue.

Understanding Subfalcine Herniation

Subfalcine herniation, also known as cingulate herniation, is a type of brain herniation where a portion of the brain pushes or shifts under the falx cerebri, a membrane that separates the two cerebral hemispheres. Moreover, this displacement occurs due to increased intracranial pressure (ICP) or the presence of space-occupying lesions within the brain.

Etiology of Subfalcine Herniation

Subfalcine herniation is a secondary intracranial injury that occurs as a result of various primary injuries, characterized by changes in brain volume, cerebrospinal fluid (CSF) volume, and intracranial blood volume. These primary injuries set the stage for the subsequent displacement of brain tissue beneath the falx cerebri, leading to subfalcine herniation. Therefore, understanding the etiology of this condition is essential for diagnosing and managing patients effectively.

Primary Injuries Leading to Subfalcine Herniation

Increased Brain Volume:

• Traumatic Brain Injury (TBI): One of the leading causes of increased brain volume, TBI results from head trauma and can lead to brain swelling.
• Hemorrhage: Hemorrhagic events such as epidural, subdural, and intraparenchymal bleeding contribute to increased intracranial pressure due to the accumulation of blood within the brain.
• Ischemia due to Stroke: Stroke, which disrupts blood flow to the brain, can lead to tissue swelling, increasing intracranial pressure.

Tumor:

• Brain tumors, both benign and malignant, can grow and displace brain tissue, contributing to the development of subfalcine herniation.

Cytotoxic/Vasogenic/Osmotic Edema:

• Edema, which refers to the accumulation of fluid in brain tissue, can occur due to various factors and lead to an increase in brain volume.

Status Epilepticus:

• Prolonged seizures can result in increased brain volume, potentially leading to subfalcine herniation.

Hyperosmolality:

• Conditions such as hyponatremia can cause hyperosmolality, leading to shifts in brain volume.

Diabetic Ketoacidosis/Diabetes Insipidus and Hyperammonemia:

• Metabolic disorders like diabetic ketoacidosis and diabetes insipidus, as well as elevated ammonia levels, can cause changes in brain volume.

Change in CSF Volume:

Increase in CSF Volume:

• Various factors can lead to an increase in cerebrospinal fluid volume, including choroid plexus tumors, obstructive and non-obstructive hydrocephalus, pseudotumor cerebri, and meningeal inflammation or granulomas.

Change in Intracranial Blood Volume:

Increase in Blood Volume:

• Loss of autoregulation due to TBI, increased cerebral blood flow (due to hypercapnia or hypoxia), venous sinus thrombosis, elevated right atrial pressure (heart failure), and acidosis can all result in increased intracranial blood volume, setting the stage for subfalcine herniation.

Decrease in Blood Volume:

• Rapid decompression of a hematoma, while potentially beneficial in some cases, can also lead to decreased intracranial blood volume, contributing to the complex etiology of subfalcine herniation.

Symptoms of Subfalcine Herniation

The symptoms of subfalcine herniation include:

Altered Mental Status

Subfalcine herniation often results in changes in mental function, which may range from mild confusion to profound alteration of consciousness. Patients may appear disoriented, drowsy, or even comatose. These changes in mental status are indicative of the pressure on the brain and its associated functions.

Headache

A persistent and severe headache is a common symptom of subfalcine herniation. This headache is typically described as intense and often differs from routine headaches. It is usually not relieved by over-the-counter pain medications.

Focal Neurological Deficits

Depending on which brain structures are affected by the herniation, patients may experience focal neurological deficits. These may include weakness, numbness, or loss of function in specific body parts, depending on the region of the brain being compressed.

Seizures

Subfalcine herniation can lead to the development of seizures. These may manifest as abnormal movements, convulsions, or alterations in consciousness. The increased pressure within the brain can trigger abnormal electrical activity.

Vomiting and Nausea

Patients with subfalcine herniation often experience persistent vomiting and nausea. This is a result of the elevated intracranial pressure affecting the brain’s control centers for nausea and vomiting.

Papilledema

Papilledema is the swelling of the optic disc at the back of the eye. Eye examination manifests it as a sign of increased intracranial pressure. Although not a direct symptom, it is an important clinical sign of subfalcine herniation.

Hemiparesis or Hemiplegia

In cases where the herniation leads to compression of specific motor areas of the brain, patients may exhibit weakness or paralysis on one side of the body. This can manifest as difficulty moving an arm or leg on one side.

Changes in Pupillary Responses

The size and reactivity of the pupils can change in response to subfalcine herniation. Anisocoria (unequal pupil size) or sluggish pupillary responses can be indicative of increased intracranial pressure and brain herniation.

Radiographic Features

Radiographic imaging plays a crucial role in diagnosing subfalcine herniation. Various imaging studies reveal several radiographic features, such as computed tomography (CT) scans and magnetic resonance imaging (MRI), which help confirm the presence of subfalcine herniation and provide valuable information about its extent and underlying causes. Moreover, here are the key radiographic features of subfalcine herniation:

Midline Shift

Subfalcine herniation typically causes a noticeable shift of brain structures toward the opposite cerebral hemisphere. On radiographic images, such as CT or MRI scans, this is evident as a midline shift, with the affected hemisphere appearing compressed and pushed away from the midline of the brain.

Cingulate Gyrus Displacement

The most characteristic feature of subfalcine herniation is the displacement of the cingulate gyrus. On radiographs shows the cingulate gyrus, a curved structure above the corpus callosum, shifting under the falx cerebri, which is a membrane that separates the cerebral hemispheres. Moreover, this displacement is a visible deviation from its usual position.

Sulcal Effacement

As the cingulate gyrus displaces, the sulci (the small, grooved furrows on the brain’s surface) in the affected hemisphere may become compressed, leading to sulcal effacement. Furthermore, imaging identifies it as the smoothing out or disappearance of these grooves.

Ventricular Compression

Subfalcine herniation can also affect the lateral ventricles. Radiographic images may reveal compression or displacement of the ventricles within the affected hemisphere, indicating increased intracranial pressure.

Mass Effect

In cases where a mass lesion, such as a tumor or hematoma, causes subfalcine herniation, radiographic imaging shows the presence of the lesion itself. The mass appears as an abnormal, well-defined structure that contributes to the displacement of brain tissue.

Underlying Lesions

Radiographic studies can identify the underlying causes of subfalcine herniation, such as hemorrhage, tumors, or edema. A CT scan or MRI may reveal the location, size, and characteristics of these lesions.

Contralateral Ventricular Enlargement

In some cases, subfalcine herniation can result in an increase in the size of the contralateral (opposite) ventricle. The brain exhibits this as a compensatory mechanism to accommodate the displaced brain tissue.

Diagnosis

Diagnosing subfalcine herniation is a critical medical assessment that requires a combination of clinical evaluation and radiographic imaging studies. Moreover, timely diagnosis is essential for appropriate management and intervention. The diagnosis of subfalcine herniation involves the following steps:

Clinical Assessment:

History: A detailed medical history is obtained, focusing on the patient’s presenting symptoms, any recent head trauma, underlying medical conditions, or medications.

Physical Examination: A thorough neurological examination is conducted to assess the patient’s mental status, cranial nerve function, motor strength, reflexes, and sensory functions. Particular attention is paid to any focal neurological deficits, which may indicate the presence of subfalcine herniation.

Imaging Studies:

Computed Tomography (CT) Scan: A CT scan of the head is often the initial imaging modality used to assess the brain. Radiographic features on the CT scan that suggest subfalcine herniation include midline shift, displacement of brain structures, and possible mass lesions. It can also help identify the underlying causes, such as hemorrhage, tumors, or edema.

Magnetic Resonance Imaging (MRI): MRI provides more detailed and high-resolution images of brain structures. It can confirm the presence of subfalcine herniation and offer valuable information about the extent of displacement, the specific structures affected, and any underlying pathologies. It is particularly useful in identifying edema and brain tumors.

Intracranial Pressure Monitoring:

In severe cases where the diagnosis and treatment of elevated intracranial pressure are critical, intracranial pressure monitoring may be employed. This involves placing a catheter or sensor within the brain to directly measure intracranial pressure levels.

Laboratory Tests:

Depending on the suspected underlying cause of subfalcine herniation, additional laboratory tests may be performed. For example, if infection is suspected, cerebrospinal fluid analysis or blood tests may be conducted to identify specific pathogens or abnormalities.

Electroencephalogram (EEG):

In cases where there is a suspicion of seizures or status epilepticus as a cause of subfalcine herniation, an EEG may be conducted to evaluate electrical brain activity and detect any abnormal patterns associated with seizures.

Lumbar Puncture (Spinal Tap):

While lumbar puncture is not typically used to diagnose subfalcine herniation, it may be employed in specific cases to rule out certain conditions or assess cerebrospinal fluid characteristics.

Treatment and Management

The treatment and management of subfalcine herniation, a critical neurological emergency characterized by the displacement of brain tissue under the falx cerebri due to increased intracranial pressure, aim to address the underlying causes and relieve pressure on the brain. Swift intervention is crucial for optimal outcomes. Here is a comprehensive overview of the treatment and management of subfalcine herniation:

Stabilization and Monitoring:

The patient’s vital signs, including blood pressure, heart rate, and oxygen saturation, are closely monitored.

Continuous neurological assessment is conducted to evaluate mental status, pupillary responses, motor function, and other neurological signs.

Emergent Airway Management:

In cases where the patient is unable to maintain their airway or has reduced consciousness, endotracheal intubation and mechanical ventilation may be necessary to ensure adequate oxygenation.

Elevating the Head of the Bed:

Elevating the head of the patient’s bed to a 30-45 degree angle can help reduce intracranial pressure by facilitating venous drainage from the brain.

Control of Blood Pressure:

Elevated blood pressure can exacerbate intracranial pressure. Medications may be administered to control blood pressure and ensure it remains within an acceptable range.

Osmotic Agents:

Osmotic agents such as mannitol or hypertonic saline are used to draw excess fluid out of brain tissue, reducing cerebral edema and intracranial pressure. These are typically administered intravenously.

Diuretics:

Diuretics like furosemide may be used to help reduce cerebral edema and lower intracranial pressure.

Sedation and Analgesia:

Sedative medications can be used to keep the patient calm and minimize agitation. Analgesics can provide pain relief if necessary.

Treatment of Underlying Causes:

The specific underlying cause of subfalcine herniation must be addressed. For example, if the herniation is due to hemorrhage, surgical evacuation of the hematoma may be required. In the case of tumors, surgery, radiation therapy, or chemotherapy may be indicated.

Management of Seizures:

If seizures are a contributing factor, anticonvulsant medications may be administered to control seizure activity.

Intracranial Pressure Monitoring:

In some cases, intracranial pressure monitoring is initiated to continuously monitor the patient’s ICP and guide treatment decisions.

Surgical Intervention:

In severe and life-threatening cases, surgical intervention may be necessary. Moreover, decompressive craniectomy involves the removal of part of the skull to allow the brain to expand and relieve pressure.

Intensive Care Unit (ICU) Care:

Patients with subfalcine herniation typically require admission to an ICU for close monitoring and intensive care.

Rehabilitation:

After stabilization and successful treatment of the underlying cause, patients may require rehabilitation services to regain lost functions and improve quality of life.

Conclusion

Subfalcine herniation is a serious medical condition that demands prompt diagnosis and intervention. Hence, understanding its causes, symptoms, diagnosis, and treatment options is essential for healthcare providers and the general public alike. Moreover, by increasing awareness and knowledge of this condition, we can contribute to improved outcomes and better management of patients at risk for subfalcine herniation. If you or someone you know experiences symptoms associated with this condition, seek immediate medical attention to prevent severe complications.

References

Kostecki, K., De Jesus, O., & Pearson-Shaver, A. L. (2019). Subfalcine Herniation.

Riveros Gilardi, B., Muñoz López, J. I., Hernández Villegas, A. C., Garay Mora, J. A., Rico Rodríguez, O. C., Chávez Appendini, R., … & Higuera Calleja, J. A. (2019). Types of cerebral herniation and their imaging features. Radiographics, 39(6), 1598-1610.

Byard, R. W. (2013). Patterns of cerebral and cerebellar herniation. Forensic Science, Medicine, and Pathology, 9, 260-264.