Magnetic resonance imaging findings of Kernohan–Woltman notch in acute subdural hematoma (2022)

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Clinical Neurology and Neurosurgery

Volume 101, Issue 2,

June 1999

, Pages 122-124

Abstract

Objective and importance: We report the case of a 73-year-old patient who presented a right motor deficit caused by an ipsilateral acute subdural hematoma. A magnetic resonance imaging (MRI) demonstration of Kernohan–Woltman notch phenomenon was obtained. Clinical presentation: The woman sustained a major head injury at home, followed by loss of consciousness. On admission to the emergency room, she was comatose, anisochoric (left>right), and showed a reaction to pain with decerebrating movements of left limbs (Glasgow Coma Scale (GCS) 4/15). A right severe hemiparesis was observed. Cerebral computed tomography scan showed a large right hemispheric subdural hematoma. Intervention and post-operative course: A wide right craniotomy was performed and the subdural hematoma evacuated. During the post-operative period, the level of consciousness gradually improved. A MRI performed about 2 weeks after operation showed a small area of abnormal signal intensity in the left cerebral peduncle. On discharge, the woman was able to communicate with others, but her right hemiparesis was still severe.

Introduction

The compression of a contralateral cerebral peduncle against the edge of the tentorium caused by a supratentorial mass, with ipsilateral motor deficit, was first described by Kernohan and Woltman [1], who observed this phenomenon in a patient suffering from a right fronto-temporal brain tumor. Subsequently, several observations have been reported in patients with major head injury and brain tumors [2], [3], [4], [5], [6], [7], [8]. We describe a case of Kernohan–Woltman notch phenomenon (KWNP) secondary to acute post-traumatic subdural hematoma, in which the damage of contralateral cerebral peduncle has been verified by post-operative cerebral magnetic resonance imaging (MRI).

Section snippets

Case report

On going down the staircase in her home, a 73-year-old woman slipped along steps and sustained a severe head injury, immediately followed by loss of consciousness. On first neurological examination in the emergency room, she appeared to be comatose, with a Glasgow Coma Scale (GCS) of 4/15. Pupils were anisochoric (left>right) and a decerebrating reaction with left limbs was observed. A severe motor deficit on right hemisoma was also present. Cerebral computed tomography (CT) scan urgently

Discussion

KWNP can be the cause of false localizing motor sign. The large right acute subdural hematoma observed in our patient produced an ipsilateral transtentorial uncal herniation and a compression of contralateral cerebral peduncle against the edge of the tentorium, with severe damage of the left corticospinal tract and a transient lesion of the Edinger–Westphal nucleus of the left third cranial nerve. The MRI performed 2 weeks after the operation confirmed this interpretation, revealing a small

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Cited by (14)

  • Kernohan-Woltman notch phenomenon secondary to a cranial epidural hematoma

    2014, Revista Espanola de Anestesiologia y Reanimacion

    El fenómeno de la escotadura de Kernohan-Woltman es una manifestación neurológica paradójica que consiste en un déficit motor ipsilateral a la lesión cerebral primaria. Este fenómeno es causado principalmente por hematomas subdurales agudos o crónicos postraumáticos, siendo los hematomas epidurales una causa menos frecuente. Este fenómeno debe ser tenido en cuenta en casos de déficit motor ipsilateral, ya que puede resultar en procedimientos quirúrgicos del lado equivocado. Presentamos el caso de un paciente de 40 años quien, tras sufrir un traumatismo craneoencefálico, presentó disminución del nivel de conciencia y anisocoria. La tomografía computarizada de cráneo evidenció un hematoma epidural parietofrontal derecho con desplazamiento de la línea media y herniación uncal. Se realizó craneotomía y drenaje del hematoma y al sexto día del postoperatorio se evidenció una hemiparesia braquiocrural derecha. En la resonancia magnética se observó un área de isquemia capsulopeduncular izquierda acorde con el diagnóstico de fenómeno de la escotadura de Kernohan-Woltman.

    Kernohan-Woltman notch phenomenon is a paradoxical neurological manifestation which involves a motor deficit on the same side as the primary brain injury. It is produced mainly by acute or chronic subdural hematomas, and less frequently by post-traumatic epidural ones. It should be taken into consideration in cases of ipsilateral motor deficit, as it may lead to surgical procedures being performed on the incorrect side. We report the case of a 40 year old man who sustained a major head injury which was followed by a decreased level of consciousness and anisocoria. Computed tomography of the brain revealed a frontal and parietal epidural hematoma with right midline shift and uncal herniation. Craniotomy and drainage of the hematoma was performed, and on the sixth day after surgery it was observed that the patient had a brachio-crural right hemiparesis. Magnetic resonance imaging showed an ischemic area on the left capsule and cerebral peduncle consistent with the diagnosis of Kernohan-Woltman notch phenomenon.

  • Acute subdural hematoma after spinal anesthesia in an obstetric patient

    2008, Journal of Clinical Anesthesia

    Magnetic resonance imaging is useful in observing this phenomenon. There are various cases of subdural hematomas in the literature in which MRI detected hypodense lesions at T1 and hypertense lesions at T2 of the damaged cerebral peduncle lateral to the lesion [8-10]. Using transcranial electrical motor evoked potentials, Binder et al. [11] showed both a marked increase in voltage threshold as well as a reduction in the complexity of the motor evoked potential waveform on the hemiparetic side.

    Intracranial subdural hematoma is a serious complication of spinal anesthesia. We report the case of a 31-year-old woman who presented with headache and neurologic localizing signs after spinal anesthesia for cesarean delivery. She was subsequently diagnosed with a right temporoparietal subdural hematoma. The hematoma was evacuated, and she had good recovery.

  • Kernohan's notch phenomenon in chronic subdural hematoma: MRI findings

    2007, Journal of Clinical Neuroscience

    Although most commonly seen in this setting, several studies have also reported patients with traumatic head injury or spontaneous intracerebral accident with definitive evidence of Kernohan’s notch on MRI. The majority of reported cases have been related to acute space-occupying lesions such as a subdural hematoma,5–10 epidural hematoma,11,12 depressed skull fracture13 or spontaneous intracerebral hematoma.1,14,15 Only two patients with chronic subdural hematoma2,3 have been reported with MRI.

    We report two cases of Kernohan’s notch phenomenon secondary to chronic subdural hematoma detected by MRI. In the first case, the patient was drowsy with an oculomotor palsy and a hemiparesis ipsilateral to the chronic subdural hematoma. MRI in the post-operative period showed no abnormal signal or deformity of the crus cerebri. The neurological signs immediately resolved after trephination. In the second case, the patient was admitted with progressive decrease in their level of consciousness and ipsilateral hemiparesis with the chronic subdural hematoma. MRI on admission revealed an abnormal signal in the contralateral crus cerebri against the chronic subdural hematoma. After surgery, the mental state gradually recovered to normal with some degree of residual hemiparesis. In patients with chronic subdural hematoma, a compressive deformity of the crus cerebri, without abnormal signal on MRI, may predict a better neurological recovery in patients with Kernohan’s notch phenomenon.

  • Contralateral mesencephalic injury due to tentorial uncal herniation. Magnetic resonance imaging of the Kernohan's notch

    2004, Neurocirugia

    Presentamos un caso de hemiparesia ipsilateral a un hematoma extradural traumático, como consecuencia de la denominada “Hendidura de Kernohan” (Kernohan’s notch). Documentamos la lesión mediante imágenes axiales y coronales en resonancia magnética.

    We report a case of a traumatic epidural hematoma with ipsilateral hemiparesis, due to the so-called Kernohan’s notch. We document the injury with axial and coronal magnetic resonance imaging.

  • Kernohan–Woltman notch phenomenon: a review article

    2017, British Journal of Neurosurgery

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