PMC6794605_01
Duret hemorrhages due to traumatic transtentorial herniation. Representative axial images are shown at the levels of the caudal midbrain (top row) and rostral pons (bottom row). In the caudal midbrain, a Duret hemorrhage is indicated by curvilinear hypointense signal at the midline on the susceptibility-weighted angiography (SWAN) image, which corresponds with a hyperintensity on the T2-weighted image (T2) and diffusion-weighted image (DWI), as well as a hypointensity on the apparent diffusion coefficient (ADC) map (solid arrows). A second hypointense lesion is seen in the rostral pons on the SWAN image. The signal properties of this second lesion are similar on the diffusion-weighted image and apparent diffusion coefficient map (dashed arrows), but no corresponding hyperintensity is seen on the T2-weighted image. A T2-hyperintense lesion within the right cerebral peduncle (arrow head) at the level of the caudal midbrain likely represents injury to the descending corticospinal tract fibers due to compression against the tentorium during the herniation event.
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F1
The susceptibility-weighted angiography (SWAN) sequence demonstrated hemorrhages in the caudal midbrain and rostral pons that had not been detected by prior head CT scans (Figure 1).
Multifocal infarctions due to vascular compression during transtentorial herniation. Representative diffusion-weighted images (DWI; top row) and apparent diffusion coefficient (ADC; bottom row) images demonstrate ischemic infarctions with the anterior cerebral artery, middle cerebral artery, and posterior cerebral artery territories. The infarctions are indicated by hyperintense signal on DWI and corresponding hypointense signal on ADC. At the time of this MRI scan (post-herniation day 6), the patient's behavioral assessment indicated a minimally conscious state.
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F2
The diffusion-weighted imaging and apparent diffusion coefficient data confirmed acute infarcts in the left ACA, MCA, and PCA territories (Figure 2).