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Brain herniation
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<h2 id="signs-and-symptoms">Signs and symptoms</h2> <p>Brain herniation frequently presents with <a href="/facts/Abnormal_posturing/tsujLk0W">abnormal posturing</a>,<a class="footnote-ref" id="fnref:3" href="#fn:3"><sup>3</sup></a> a characteristic positioning of the limbs indicative of severe brain damage. These patients have a lowered <a href="/facts/Altered_level_of_consciousness/bzGqcsUV">level of consciousness</a>, with <a href="/facts/Glasgow_Coma_Score/PsQ56f9t">Glasgow Coma Scores</a> of three to five. <a href="/facts/Coma/N9oQ7g7R">Coma</a> and <a href="/facts/Persistent_vegetative_state/EkAyEEU3">persistent vegetative state</a> also occurs.<a class="footnote-ref" id="fnref:4" href="#fn:4"><sup>4</sup></a> One or both <a href="/facts/Pupil/E4ec4lfJ">pupils</a> may be <a href="/facts/Mydriasis/19r5uMvC">dilated</a> and fail to <a href="/facts/Pupillary_response/0wP5p5KL">constrict</a> <a href="/facts/Pupillary_light_reflex/owbnYMTj">in response to light</a>.<a class="footnote-ref" id="fnref:5" href="#fn:5"><sup>5</sup></a> Vomiting can also occur due to compression of the <a href="/facts/Vomiting_center/BpamdEYb">vomiting center</a> in the <a href="/facts/Medulla_oblongata/KdSbCCkB">medulla oblongata</a>. Severe <a href="/facts/Headaches/mdmmC9DP">headaches</a> and <a href="/facts/Seizures/zuIrQyze">seizures</a> as a result of increased intracranial pressure are not uncommon. <a href="/facts/Cardiovascular/WXwudzzc">Cardiovascular</a> and pulmonary symptoms may also be present as the brain loses function, but might also be associated with <a href="/facts/Bleeding/CGyFMU0F">bleeding</a>. These symptoms are known as <a href="/facts/Cushing_reflex/bVIFtCDS">Cushing's Triad</a>: <a href="/facts/Hypertension/wlAvBfcf">hypertension</a> (with widening <a href="/facts/Pulse_pressure/IhNXw47K">pulse pressure</a>), irregular respirations (commonly <a href="/facts/Cheyne%25E2%2580%2593Stokes_respiration/R9sFPqTD">Cheyne-Stokes</a>), <a href="/facts/Bradycardia/70msP5HD">bradycardia</a> and in severe cases <a href="/facts/Cardiac_arrest/HIAm9AWX">cardiac arrest</a>.<a class="footnote-ref" id="fnref:6" href="#fn:6"><sup>6</sup></a><a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a> </p> <h2 id="causes">Causes</h2> <p>Causes of brain herniation include:<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a> </p> <ul><li><a href="/facts/Brain_edema/UDlqKHrV">Brain edema</a></li> <li><a href="/facts/Hematoma/p5xtzwaJ">Hematoma</a></li> <li><a href="/facts/Stroke/DwpjdzY0">Stroke</a></li> <li><a href="/facts/Brain_tumor/avjI5Nhm">Tumour</a></li> <li><a href="/facts/List_of_infections_of_the_central_nervous_system/Xo07WjcD">Infection</a></li></ul> <h2 id="classification">Classification</h2> <p>The <a href="/facts/Cerebellar_tentorium/xb4xhk3u">tentorium</a> is an extension of the dura mater that separates the <a href="/facts/Cerebellum/kBRS2Lou">cerebellum</a> from the <a href="/facts/Cerebrum/zjpAVDgA">cerebrum</a>. There are two major classes of herniation: supratentorial and infratentorial. Supratentorial refers to herniation of structures normally found above the <a href="/facts/Tentorial_notch/1R88xX8T">tentorial notch</a>, and infratentorial refers to structures normally found below it.<a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> </p> <ul><li>Supratentorial herniation</li></ul> <p>1) <a href="/facts/Uncus/P8cyLwfa">Uncal</a> (transtentorial) </p><p>2) Central </p><p>3) <a href="/facts/Cingulate_gyrus/Eerbtdvr">Cingulate</a> (<a href="/facts/Falx_cerebri/A9Fqabrr">subfalcine</a> or transfalcine) </p><p>4) <a href="/facts/Calvarium/mxpEghJy">Transcalvarial</a> </p><p>5) <a href="/facts/Tectal/NXpE9WXV">Tectal</a> (posterior) </p> <ul><li>Infratentorial herniation</li></ul> <p>6) Upward (upward cerebellar or upward transtentorial) </p><p>7) <a href="/facts/Cerebellar_tonsil/IDpn4FSP">Tonsillar</a> (downward cerebellar) </p> <h3>Uncal herniation</h3> <p>In uncal herniation, a common subtype of transtentorial herniation, the innermost part of the <a href="/facts/Temporal_lobe/U2wLVCrg">temporal lobe</a>, the <a href="/facts/Uncus/P8cyLwfa">uncus</a>, can be squeezed so much that it moves towards the <a href="/facts/Tentorium_cerebelli/xb4xhk3u">tentorium</a> and puts pressure on the <a href="/facts/Brainstem/lD3WQbXM">brainstem</a>, most notably the midbrain.<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a> The tentorium is a structure within the <a href="/facts/Human_skull/A9Wp63Np">skull</a> formed by the dura mater of the meninges. Tissue may be stripped from the <a href="/facts/Cerebral_cortex/GpXosGHP">cerebral cortex</a> in a process called <a href="/facts/Decortication/XjbXuv8A">decortication</a>.<a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a> </p><p>The uncus can squeeze the <a href="/facts/Oculomotor_nerve/eu6TGIoI">oculomotor nerve</a> (a.k.a. CN III), which may affect the <a href="/facts/Parasympathetic/eNzCI8Yu">parasympathetic</a> input to the <a href="/facts/Human_eye/a24ua4fy">eye</a> on the side of the affected nerve, causing the <a href="/facts/Pupil_(eye)/E4ec4lfJ">pupil</a> of the affected eye to <a href="/facts/Pupillary_dilation/0wP5p5KL">dilate</a> and fail to constrict in response to light as it should. Pupillary dilation often precedes the somatic motor effects of CN III compression called <a href="/facts/Oculomotor_nerve_palsy/Bo9t9ye2">oculomotor nerve palsy</a> or third nerve palsy. This palsy presents as deviation of the eye to a "down and out" position due to loss of innervation to all <a href="/facts/Ocular_muscles/GSPIvJrN">ocular motility muscles</a> except for the <a href="/facts/Lateral_rectus_muscle/ewz9BM99">lateral rectus</a> (innervated by <a href="/facts/Abducens_nerve/xp8KDQYr">abducens nerve</a> (a.k.a. CN VI) and the <a href="/facts/Superior_oblique_muscle/woEB19dB">superior oblique</a> (innervated by <a href="/facts/Trochlear_nerve/nWA4tb8y">trochlear nerve</a> a.k.a. CN IV). The symptoms occur in this order because the parasympathetic fibers surround the motor fibers of CN III and are hence compressed first. </p><p>Compression of the ipsilateral <a href="/facts/Posterior_cerebral_artery/HWchoPmM">posterior cerebral artery</a> will result in ischemia of the ipsilateral primary visual cortex and contralateral visual field deficits in both eyes (contralateral <a href="/facts/Homonymous_hemianopsia/2bPz5GjW">homonymous hemianopsia</a>). </p><p>Another important finding is a <i>false localizing sign</i>, the so-called <a href="/facts/Kernohan%2527s_notch/Y47QH45z">Kernohan's notch</a>, which results from compression of the contralateral<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a> <a href="/facts/Cerebral_crus/tXCLJx8D">cerebral crus</a> containing descending <a href="/facts/Corticospinal_tract/txupaYD6">corticospinal</a> and some <a href="/facts/Corticobulbar_tract/4oFMX0o6">corticobulbar</a> tract fibers. This leads to Ipsilateral <a href="/facts/Hemiparesis/W44QM11N">hemiparesis</a> in reference to the herniation and contralateral hemiparesis with reference to the cerebral crus. </p><p>With increasing pressure and progression of the hernia there will be distortion of the brainstem leading to <a href="/facts/Duret_hemorrhage/JjRxHWz0">Duret hemorrhages</a> (tearing of small vessels in the <a href="/facts/Parenchyma/NlGkFWlQ">parenchyma</a>) in the median and paramedian zones of the <a href="/facts/Mesencephalon/NXpE9WXV">mesencephalon</a> and <a href="/facts/Pons/McS272JS">pons</a>. The rupture of these vessels leads to linear or flamed shaped hemorrhages. The disrupted brainstem can lead to <a href="/facts/Decorticate_posture/tsujLk0W">decorticate posture</a>, respiratory center depression and death. Other possibilities resulting from brain stem distortion include <a href="/facts/Lethargy/wJFlYuB7">lethargy</a>, slow heart rate, and <a href="/facts/Mydriasis/19r5uMvC">pupil dilation</a>.<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a> </p><p>Uncal herniation may advance to central herniation.<a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a> The sliding uncus syndrome represents uncal herniation without alteration in the level of consciousness and other sequelae mentioned above. </p> <h3>Central herniation</h3> <p>In <i>central herniation</i>, the <a href="/facts/Diencephalon/I31JJj2j">diencephalon</a> and parts of the <a href="/facts/Temporal_lobes/U2wLVCrg">temporal lobes</a> of both of the <a href="/facts/Cerebral_hemisphere/H81aw2Qy">cerebral hemispheres</a> are squeezed through a notch in the <a href="/facts/Tentorium_cerebelli/xb4xhk3u">tentorium cerebelli</a>.<a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a><a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a> Transtentorial herniation can occur when the brain moves either up or down across the tentorium, called ascending and descending transtentorial herniation respectively; however descending herniation is much more common.<a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a> Downward herniation can stretch branches of the <a href="/facts/Basilar_artery/Krm82RGT">basilar artery</a> (pontine arteries), causing them to tear and bleed, known as a <a href="/facts/Duret_hemorrhage/JjRxHWz0">Duret hemorrhage</a>. The result is usually fatal.<a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a> Other symptoms of this type of herniation include small, fixed pupils with<a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a> paralysis of upward eye movement giving the characteristic appearance of "sunset eyes". Also found in these patients, often as a terminal complication is the development of <a href="/facts/Diabetes_insipidus/mtAXABCU">diabetes insipidus</a> due to the compression of the pituitary stalk. Radiographically, downward herniation is characterized by obliteration of the <a href="/facts/Chiasmatic_cistern/EJwQxhG0">suprasellar cistern</a> from temporal lobe herniation into the tentorial hiatus with associated compression on the cerebral peduncles. Upwards herniation, on the other hand, can be radiographically characterized by obliteration of the quadrigeminal cistern. Intracranial hypotension syndrome has been known to mimic downwards transtentorial herniation. </p> <h3>Cingulate herniation</h3> <p>In <i>cingulate</i> or <i>subfalcine herniation</i>, the most common type, the innermost part of the <a href="/facts/Frontal_lobe/RvokInmf">frontal lobe</a> is scraped under part of the <a href="/facts/Falx_cerebri/A9Fqabrr">falx cerebri</a>, the dura mater at the top of the head between the two <a href="/facts/Brain_hemisphere/H81aw2Qy">hemispheres of the brain</a>.<a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a><a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a> Cingulate herniation can be caused when one hemisphere swells and pushes the <a href="/facts/Cingulate_gyrus/Eerbtdvr">cingulate gyrus</a> by the falx cerebri.<a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a> This does not put as much pressure on the brainstem as the other types of herniation, but it may interfere with <a href="/facts/Blood_vessel/FG3GjPNW">blood vessels</a> in the frontal lobes that are close to the site of injury (anterior cerebral artery), or it may progress to central herniation.<a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a> Interference with the blood supply can cause dangerous increases in ICP that can lead to more dangerous forms of herniation.<a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a> Symptoms for cingulate herniation are not well defined.<a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a> Usually occurring in addition to uncal herniation, cingulate herniation may present with <a href="/facts/Abnormal_posturing/tsujLk0W">abnormal posturing</a> and <a href="/facts/Coma/N9oQ7g7R">coma</a>.<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a> Cingulate herniation is frequently believed to be a precursor to other types of herniation.<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a> </p> <h3>Transcalvarial herniation</h3> <p>In <i>transcalvarial herniation</i>, the brain squeezes through a fracture or a surgical site in the skull.<a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a> Also called "external herniation", this type of herniation may occur during <a href="/facts/Craniectomy/jEdLe5LL">craniectomy</a>, surgery in which a flap of skull is removed, the protruding brain region preventing the piece of skull from being replaced during the operation.<a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> </p> <h3>Upward herniation</h3> <p>Increased pressure in the posterior <a href="/facts/Posterior_cranial_fossa/mXEPvv7u">fossa</a> can cause the <a href="/facts/Cerebellum/kBRS2Lou">cerebellum</a> to move up through the tentorial opening in <i>upward</i>, or <i>cerebellar herniation</i>.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> The <a href="/facts/Midbrain/NXpE9WXV">midbrain</a> is pushed through the tentorial notch upward. This is also known as ascending transtentorial herniation since it occurs across the tentorium cerebelli. </p> <h3>Tonsillar herniation</h3> <p>In <i>tonsillar herniation</i>, also called <i>downward cerebellar herniation</i>,<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> transforaminal herniation, or "coning", the cerebellar tonsils move downward through the <a href="/facts/Foramen_magnum/nlxwvfuU">foramen magnum</a> possibly causing compression of the lower brainstem and upper cervical spinal cord as they pass through the foramen magnum.<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a> Increased pressure on the brainstem can result in dysfunction of the centers in the brain responsible for controlling respiratory and cardiac function. The most common signs are intractable headache, head tilt, and neck stiffness due to tonsillar impaction. The level of consciousness may decrease and also give rise to flaccid paralysis. Blood pressure instability is also evident in these patients.<a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a> </p><p>Congenital tonsillar herniation of the <a href="/facts/Cerebellum/kBRS2Lou">cerebellum</a> is also known as a <a href="/facts/Chiari_malformation/9BKbwYzr">Chiari malformation</a> (CM), or previously an Arnold-Chiari malformation (ACM). There are four types of Chiari malformation, and they represent very different disease processes with different symptoms and prognosis. These conditions can be found in asymptomatic patients as an incidental finding, or can be so severe as to be life-threatening. This condition is now being diagnosed more frequently by radiologists, as more patients undergo MRI scans of their heads, especially upright MRI, which is more than twice as sensitive for detecting this condition.<a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a> Cerebellar tonsillar ectopia (CTE) is a term used by radiologists to describe cerebellar tonsils that are "low lying" but that do not meet the radiographic criteria for definition as a Chiari malformation. The currently accepted radiographic definition for a Chiari malformation is that cerebellar tonsils lie at least 5mm below the level of the foramen magnum. Some clinicians have reported that some patients appear to experience symptoms consistent with a Chiari malformation without radiographic evidence of tonsillar herniation. Sometimes these patients are described as having a 'Chiari [type] 0'. </p><p>There are many suspected causes of tonsillar herniation including: decreased or malformed posterior fossa (the lower, back part of the skull) not providing enough room for the cerebellum; hydrocephalus or abnormal CSF volume pushing the tonsils out; or dural tension pulling the brain caudally. Connective tissue disorders, such as <a href="/facts/Ehlers_Danlos_syndrome/UyXa1bJ5">Ehlers Danlos syndrome</a>, can be associated. </p><p>For further evaluation of tonsillar herniation, CINE flow studies are used. This type of MRI examines flow of CSF at the cranio-cervical joint. For persons experiencing symptoms but without clear MRI evidence, especially if the symptoms are better in the supine position and worse upon standing/upright, an upright MRI may be useful.<a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a> </p> <h2 id="treatment">Treatment</h2> <p>Treatment involves removal of the etiologic mass and <a href="/facts/Decompressive_craniectomy/jEdLe5LL">decompressive craniectomy</a>. Brain herniation can cause severe disability or death. In fact, when herniation is visible on a <a href="/facts/CT_scan/NusPJ2S8">CT scan</a>, the prognosis for a meaningful recovery of neurological function is poor.<a class="footnote-ref" id="fnref:36" href="#fn:36"><sup>36</sup></a> The patient may become paralyzed on the same side as the lesion causing the pressure, or damage to parts of the brain caused by herniation may cause paralysis on the side opposite the lesion.<a class="footnote-ref" id="fnref:37" href="#fn:37"><sup>37</sup></a> Damage to the <a href="/facts/Midbrain/NXpE9WXV">midbrain</a>, which contains the <a href="/facts/Reticular_activating_network/p3sssWXm">reticular activating network</a> which regulates <a href="/facts/Consciousness/IAxmgt6c">consciousness</a>, will result in <a href="/facts/Coma/N9oQ7g7R">coma</a>.<a class="footnote-ref" id="fnref:38" href="#fn:38"><sup>38</sup></a> Damage to the cardio-respiratory centers in the <a href="/facts/Medulla_oblongata/KdSbCCkB">medulla oblongata</a> will cause <a href="/facts/Respiratory_arrest/8lYW9Ghj">respiratory arrest</a> and (secondarily) <a href="/facts/Cardiac_arrest/HIAm9AWX">cardiac arrest</a>.<a class="footnote-ref" id="fnref:39" href="#fn:39"><sup>39</sup></a> Investigation is underway regarding the use of neuroprotective agents during the prolonged post-traumatic period of brain hypersensitivity associated with the syndrome.<a class="footnote-ref" id="fnref:40" href="#fn:40"><sup>40</sup></a> </p> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/Second-impact_syndrome/JUHgHfgc">Second-impact syndrome</a></li></ul> <h2 id="external-links">External links</h2> Wikimedia Commons has media related to Brain herniation. <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Barr RM, Gean AD, Le TH (2007). "Craniofacial trauma". In Brant WE, Helms CA (eds.). Fundamentals of Diagnostic Radiology. Philadelphia: Lippincott, Williams & Wilkins. p. 69. ISBN 978-0-7817-6135-2. Retrieved 2008-11-17. <a href="978-0-7817-6135-2" target="_blank">978-0-7817-6135-2</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Gruen P (May 2002). "Surgical management of head trauma". Neuroimaging Clinics of North America. 12 (2): 339–43. doi:10.1016/S1052-5149(02)00013-8. PMID 12391640. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>Gruen P (May 2002). "Surgical management of head trauma". Neuroimaging Clinics of North America. 12 (2): 339–43. doi:10.1016/S1052-5149(02)00013-8. PMID 12391640. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Gruen P (May 2002). "Surgical management of head trauma". Neuroimaging Clinics of North America. 12 (2): 339–43. doi:10.1016/S1052-5149(02)00013-8. PMID 12391640. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Gruen P (May 2002). "Surgical management of head trauma". Neuroimaging Clinics of North America. 12 (2): 339–43. doi:10.1016/S1052-5149(02)00013-8. PMID 12391640. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Dinallo, Sean; Waseem, Muhammad (2022), "Cushing Reflex", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 31747208, retrieved 2023-02-19 <a href="http://www.ncbi.nlm.nih.gov/books/NBK549801/" target="_blank">http://www.ncbi.nlm.nih.gov/books/NBK549801/</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Eyster, J. A. (1906-10-12). "Clinical and Experimental Observations Upon Cheyne-Stokes Respiration". The Journal of Experimental Medicine. 8 (5): 565–613. doi:10.1084/jem.8.5.565. ISSN 0022-1007. PMC 2124640. PMID 19867060. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2124640" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2124640</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>Halliday A. "Cerebral Herniation Syndromes" (PDF). Oregon Neurosurgery Specialists. Archived from the original (PDF) on 2017-04-17. Retrieved 2017-04-16. <a href="https://web.archive.org/web/20170417071802/https://www.peacehealth.org/sites/default/files/Documents/Neuro%202012%20Halliday%20Presentation.pdf" target="_blank">https://web.archive.org/web/20170417071802/https://www.peacehealth.org/sites/default/files/Documents/Neuro%202012%20Halliday%20Presentation.pdf</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>Orlando Regional Healthcare, Education and Development. 2004. "Overview of Adult Traumatic Brain Injuries." Archived 2008-02-27 at the Wayback Machine Retrieved on January 16, 2008. <a href="http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf" target="_blank">http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>Shepard S (20 August 2004). "Head trauma". Emedicine.com. Archived from the original on 8 February 2007. Retrieved 28 January 2007. <a href="https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm" target="_blank">https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>McCaffrey P (2001). "The neuroscience on the web series: CMSD 336 neuropathologies of language and cognition". California State University, Chico. Archived from the original on 6 April 2007. Retrieved 7 August 2007. <a href="https://web.archive.org/web/20070406174458/http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html" target="_blank">https://web.archive.org/web/20070406174458/http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>Robins Basic Pathology[full citation needed] <a href="/wiki/Wikipedia:Citing_sources#What_information_to_include" target="_blank">/wiki/Wikipedia:Citing_sources#What_information_to_include</a> <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>McCaffrey P (2001). "The neuroscience on the web series: CMSD 336 neuropathologies of language and cognition". California State University, Chico. Archived from the original on 6 April 2007. Retrieved 7 August 2007. <a href="https://web.archive.org/web/20070406174458/http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html" target="_blank">https://web.archive.org/web/20070406174458/http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>Orlando Regional Healthcare, Education and Development. 2004. "Overview of Adult Traumatic Brain Injuries." Archived 2008-02-27 at the Wayback Machine Retrieved on January 16, 2008. <a href="http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf" target="_blank">http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf</a> <a href="#fnref:14" class="footnote-back-ref">↩</a></p></li> <li id="fn:15"><p>Shepard S (20 August 2004). "Head trauma". Emedicine.com. Archived from the original on 8 February 2007. Retrieved 28 January 2007. <a href="https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm" target="_blank">https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm</a> <a href="#fnref:15" class="footnote-back-ref">↩</a></p></li> <li id="fn:16"><p>Cornell (1998). Introduction to neuropathology. Reaction to injury: Brain histology (Report). Cornell University Medical College. <a href="#fnref:16" class="footnote-back-ref">↩</a></p></li> <li id="fn:17"><p>Barr RM, Gean AD, Le TH (2007). "Craniofacial trauma". In Brant WE, Helms CA (eds.). Fundamentals of Diagnostic Radiology. Philadelphia: Lippincott, Williams & Wilkins. p. 69. ISBN 978-0-7817-6135-2. Retrieved 2008-11-17. <a href="978-0-7817-6135-2" target="_blank">978-0-7817-6135-2</a> <a href="#fnref:17" class="footnote-back-ref">↩</a></p></li> <li id="fn:18"><p>Cornell (1998). Introduction to neuropathology. Reaction to injury: Brain histology (Report). Cornell University Medical College. <a href="#fnref:18" class="footnote-back-ref">↩</a></p></li> <li id="fn:19"><p>Toronto Notes[full citation needed] <a href="/wiki/Wikipedia:Citing_sources#What_information_to_include" target="_blank">/wiki/Wikipedia:Citing_sources#What_information_to_include</a> <a href="#fnref:19" class="footnote-back-ref">↩</a></p></li> <li id="fn:20"><p>Shepard S (20 August 2004). "Head trauma". Emedicine.com. Archived from the original on 8 February 2007. Retrieved 28 January 2007. <a href="https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm" target="_blank">https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm</a> <a href="#fnref:20" class="footnote-back-ref">↩</a></p></li> <li id="fn:21"><p>Dawodu ST. 2007. Traumatic brain injury: Definition, epidemiology, pathophysiology. Emedicine.com. Retrieved on January 28, 2007. <a href="http://www.emedicine.com/pmr/topic212.htm" target="_blank">http://www.emedicine.com/pmr/topic212.htm</a> <a href="#fnref:21" class="footnote-back-ref">↩</a></p></li> <li id="fn:22"><p>Orlando Regional Healthcare, Education and Development. 2004. "Overview of Adult Traumatic Brain Injuries." Archived 2008-02-27 at the Wayback Machine Retrieved on January 16, 2008. <a href="http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf" target="_blank">http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf</a> <a href="#fnref:22" class="footnote-back-ref">↩</a></p></li> <li id="fn:23"><p>Shepard S (20 August 2004). "Head trauma". Emedicine.com. Archived from the original on 8 February 2007. Retrieved 28 January 2007. <a href="https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm" target="_blank">https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm</a> <a href="#fnref:23" class="footnote-back-ref">↩</a></p></li> <li id="fn:24"><p>Hudson K (2006). "Brain Herniation Syndromes - 2 Nursing CEs". Dynamic Nursing Education. Archived from the original on 10 July 2011. Retrieved 6 September 2007. <a href="https://web.archive.org/web/20110710160657/http://dynamicnursingeducation.com/class.php?class_id=37" target="_blank">https://web.archive.org/web/20110710160657/http://dynamicnursingeducation.com/class.php?class_id=37</a> <a href="#fnref:24" class="footnote-back-ref">↩</a></p></li> <li id="fn:25"><p>Hudson K (2006). "Brain Herniation Syndromes - 2 Nursing CEs". Dynamic Nursing Education. Archived from the original on 10 July 2011. Retrieved 6 September 2007. <a href="https://web.archive.org/web/20110710160657/http://dynamicnursingeducation.com/class.php?class_id=37" target="_blank">https://web.archive.org/web/20110710160657/http://dynamicnursingeducation.com/class.php?class_id=37</a> <a href="#fnref:25" class="footnote-back-ref">↩</a></p></li> <li id="fn:26"><p>Orlando Regional Healthcare, Education and Development. 2004. "Overview of Adult Traumatic Brain Injuries." Archived 2008-02-27 at the Wayback Machine Retrieved on January 16, 2008. <a href="http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf" target="_blank">http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf</a> <a href="#fnref:26" class="footnote-back-ref">↩</a></p></li> <li id="fn:27"><p>Hudson K (2006). "Brain Herniation Syndromes - 2 Nursing CEs". Dynamic Nursing Education. Archived from the original on 10 July 2011. Retrieved 6 September 2007. <a href="https://web.archive.org/web/20110710160657/http://dynamicnursingeducation.com/class.php?class_id=37" target="_blank">https://web.archive.org/web/20110710160657/http://dynamicnursingeducation.com/class.php?class_id=37</a> <a href="#fnref:27" class="footnote-back-ref">↩</a></p></li> <li id="fn:28"><p>Orlando Regional Healthcare, Education and Development. 2004. "Overview of Adult Traumatic Brain Injuries." Archived 2008-02-27 at the Wayback Machine Retrieved on January 16, 2008. <a href="http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf" target="_blank">http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf</a> <a href="#fnref:28" class="footnote-back-ref">↩</a></p></li> <li id="fn:29"><p>Barr RM, Gean AD, Le TH (2007). "Craniofacial trauma". In Brant WE, Helms CA (eds.). Fundamentals of Diagnostic Radiology. Philadelphia: Lippincott, Williams & Wilkins. p. 69. ISBN 978-0-7817-6135-2. Retrieved 2008-11-17. <a href="978-0-7817-6135-2" target="_blank">978-0-7817-6135-2</a> <a href="#fnref:29" class="footnote-back-ref">↩</a></p></li> <li id="fn:30"><p>Shepard S (20 August 2004). "Head trauma". Emedicine.com. Archived from the original on 8 February 2007. Retrieved 28 January 2007. <a href="https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm" target="_blank">https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm</a> <a href="#fnref:30" class="footnote-back-ref">↩</a></p></li> <li id="fn:31"><p>Orlando Regional Healthcare, Education and Development. 2004. "Overview of Adult Traumatic Brain Injuries." Archived 2008-02-27 at the Wayback Machine Retrieved on January 16, 2008. <a href="http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf" target="_blank">http://www.orlandoregional.org/pdf%20folder/overview%20adult%20brain%20injury.pdf</a> <a href="#fnref:31" class="footnote-back-ref">↩</a></p></li> <li id="fn:32"><p>Shepard S (20 August 2004). "Head trauma". Emedicine.com. Archived from the original on 8 February 2007. Retrieved 28 January 2007. <a href="https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm" target="_blank">https://web.archive.org/web/20070208010240/http://www.emedicine.com/med/topic2820.htm</a> <a href="#fnref:32" class="footnote-back-ref">↩</a></p></li> <li id="fn:33"><p>Toronto Notes[full citation needed] <a href="/wiki/Wikipedia:Citing_sources#What_information_to_include" target="_blank">/wiki/Wikipedia:Citing_sources#What_information_to_include</a> <a href="#fnref:33" class="footnote-back-ref">↩</a></p></li> <li id="fn:34"><p>Freeman MD, Rosa S, Harshfield D, Smith F, Bennett R, Centeno CJ, Kornel E, Nystrom A, Heffez D, Kohles SS (2010). "A case-control study of cerebellar tonsillar ectopia (Chiari) and head/neck trauma (whiplash)". Brain Injury. 24 (7–8): 988–94. doi:10.3109/02699052.2010.490512. PMID 20545453. S2CID 9553904. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:34" class="footnote-back-ref">↩</a></p></li> <li id="fn:35"><p>Gruen P (May 2002). "Surgical management of head trauma". Neuroimaging Clinics of North America. 12 (2): 339–43. doi:10.1016/S1052-5149(02)00013-8. PMID 12391640. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:35" class="footnote-back-ref">↩</a></p></li> <li id="fn:36"><p>Gruen P (May 2002). "Surgical management of head trauma". Neuroimaging Clinics of North America. 12 (2): 339–43. doi:10.1016/S1052-5149(02)00013-8. PMID 12391640. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:36" class="footnote-back-ref">↩</a></p></li> <li id="fn:37"><p>Cornell (1998). Introduction to neuropathology. Reaction to injury: Brain histology (Report). Cornell University Medical College. <a href="#fnref:37" class="footnote-back-ref">↩</a></p></li> <li id="fn:38"><p>Cornell (1998). Introduction to neuropathology. Reaction to injury: Brain histology (Report). Cornell University Medical College. <a href="#fnref:38" class="footnote-back-ref">↩</a></p></li> <li id="fn:39"><p>Cornell (1998). Introduction to neuropathology. Reaction to injury: Brain histology (Report). Cornell University Medical College. <a href="#fnref:39" class="footnote-back-ref">↩</a></p></li> <li id="fn:40"><p>Stocchetti N, Taccone FS, Citerio G, Pepe PE, Le Roux PD, Oddo M, Polderman KH, Stevens RD, Barsan W, Maas AI, Meyfroidt G, Bell MJ, Silbergleit R, Vespa PM, Faden AI, Helbok R, Tisherman S, Zanier ER, Valenzuela T, Wendon J, Menon DK, Vincent JL (April 2015). "Neuroprotection in acute brain injury: an up-to-date review". Critical Care. 19 (1): 186. doi:10.1186/s13054-015-0887-8. PMC 4404577. PMID 25896893. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404577" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404577</a> <a href="#fnref:40" class="footnote-back-ref">↩</a></p></li> </ol>