Delayed neurological improvement in a patient with Duret hemorrhage secondary to an acute subdural hematoma: illustrative case

Youngkyung Jung Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; and

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Yosef Ellenbogen Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; and

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Farhad Pirouzmand Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; and
Department of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

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BACKGROUND

Duret hemorrhage is a rare phenomenon wherein rapid transtentorial herniation results in brainstem injury and hemorrhage. It is usually regarded as a poor prognostic factor representing irreversible and often catastrophic brain injury. The authors report an unusual case of Duret hemorrhage with spontaneous delayed neurological recovery postoperatively after surgical treatment of an acute subdural hematoma (SDH).

OBSERVATIONS

The authors present the case of a 65-year-old male who initially presented to the hospital with a large acute left-sided SDH causing 1.3 cm of midline shift. He was taken urgently for a craniotomy, with no significant intraoperative swelling or visible contusions. Postoperative imaging revealed an unexpected pontine hyperdensity concerning for a Duret hemorrhage. He initially had no neurological improvement; however, at 3 weeks postoperatively, he gradually recovered and was able to follow commands and was extubated. At 10 weeks after surgery, his Glasgow Coma Scale score improved to 15, with mild residual left hemiparesis.

LESSONS

This case challenges a classic dogma that Duret hemorrhage carries a universally poor outcome. In select cases, patients can make meaningful recoveries in a delayed fashion. The lack of intraoperative contusions and swelling may have contributed to this patient’s recovery.

ABBREVIATIONS

CT = computed tomography; GCS = Glasgow Coma Scale; MRI = magnetic resonance imaging; SDH = subdural hematoma

BACKGROUND

Duret hemorrhage is a rare phenomenon wherein rapid transtentorial herniation results in brainstem injury and hemorrhage. It is usually regarded as a poor prognostic factor representing irreversible and often catastrophic brain injury. The authors report an unusual case of Duret hemorrhage with spontaneous delayed neurological recovery postoperatively after surgical treatment of an acute subdural hematoma (SDH).

OBSERVATIONS

The authors present the case of a 65-year-old male who initially presented to the hospital with a large acute left-sided SDH causing 1.3 cm of midline shift. He was taken urgently for a craniotomy, with no significant intraoperative swelling or visible contusions. Postoperative imaging revealed an unexpected pontine hyperdensity concerning for a Duret hemorrhage. He initially had no neurological improvement; however, at 3 weeks postoperatively, he gradually recovered and was able to follow commands and was extubated. At 10 weeks after surgery, his Glasgow Coma Scale score improved to 15, with mild residual left hemiparesis.

LESSONS

This case challenges a classic dogma that Duret hemorrhage carries a universally poor outcome. In select cases, patients can make meaningful recoveries in a delayed fashion. The lack of intraoperative contusions and swelling may have contributed to this patient’s recovery.

ABBREVIATIONS

CT = computed tomography; GCS = Glasgow Coma Scale; MRI = magnetic resonance imaging; SDH = subdural hematoma

Duret hemorrhage is a rare phenomenon associated with transtentorial herniation. Its pathophysiology has been attributed to the shearing of the paramedian branches of the basilar artery, reperfusion injury, and venous congestion.1 Because of its location in the brainstem, Duret hemorrhage has been traditionally associated with a very poor prognosis, often resulting in death.2,3 However, prospective studies to clarify the morbidity and mortality associated with this phenomenon are lacking.

This report describes an unusual case of a Duret hemorrhage secondary to an acute subdural hematoma (SDH), initially with poor neurological function and initially stationary postoperative neurological change followed by spontaneous improvement 3 weeks later.

Illustrative Case

We present the case of a 65-year-old male who was found to be unconscious by his family and brought to the hospital. The mechanism of injury was unclear. The patient was otherwise healthy and did not take any anticoagulants/antiplatelets. Noncontrast computed tomography (CT) of the head revealed an acute left-sided SDH with midline shift and uncal/transtentorial herniation (Fig. 1A). Clinically, his Glasgow Coma Scale (GCS) score was 3 but with intact brainstem reflexes. He was taken to the operating room, and an urgent left-sided craniotomy was performed for evacuation of the SDH. An initial postoperative CT demonstrated evacuation of the SDH with resolving mass effect (Fig. 1B); however, there was punctate pontine hemorrhage consistent with a Duret hemorrhage (Fig. 1C). His neurological examination remained poor with no significant improvement in his level of consciousness for 3 weeks. A subsequent magnetic resonance imaging (MRI) study of the brain obtained on postoperative day 6 confirmed a Duret hemorrhage (Fig. 2). A delayed CT head scan obtained 9 days postoperatively demonstrated evolving hypodensity of the pons, in keeping with evolving Duret hemorrhage. He required tracheostomy due to prolonged intubation and poor initial neurological recovery. After 3 weeks of persistent decreased level of consciousness, he spontaneously began improving to the point where he was opening his eyes spontaneously, following commands, and being able to be extubated. Six weeks later, he recovered to a modified Rankin Scale Score of 4 and was transferred to rehabilitation for ongoing care. At the 10-week follow-up, he was fully oriented, fluently conversing, and able to ambulate independently with mild left-sided weakness. His Glasgow Outcome Score (GOS) was 5.

FIG. 1
FIG. 1

A: Axial head CT of a large acute SDH with midline shift. B: Axial head CT obtained 1 day postoperatively, demonstrating improved mass effect and satisfactory evacuation of the SDH. C: Axial CT of the same postoperative scan shown in panel B, demonstrating a pontine hyperdensity. D: Delayed head CT obtained on postoperative day 9, demonstrating stable pontine hypodensity.

FIG. 2
FIG. 2

A: Axial T1-weighted MRI demonstrating hypodensity in the pons consistent with Duret hemorrhage. B: Axial T2-weighted MRI demonstrating mixed hyperintensity/hypointensity in the pons consistent with Duret hemorrhage. C: Axial diffusion-weighted image demonstrating diffusion restriction of the mixed T2 hyperintense/hypointense lesion. D: Apparent diffusion coefficient axial MRI demonstrating reduced apparent diffusion coefficient signal over the previously seen diffusion-restricting lesion in panel C.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Duret hemorrhage is an uncommon complication of rapid transtentorial herniation, the pathophysiology of which remains unclear. The most common explanation is that herniation results in shearing injury to the basilar and paramedian pontine branches. Alternatively, or perhaps in tandem, there may also be venous injury resulting in venous infarct and hemorrhage.4,5 These are a distinct entity from primary brainstem hemorrhages occurring at time of impact; however, they can be difficult to distinguish as Duret hemorrhages have been diagnosed within 30 minutes of initial injury.6 Duret hemorrhages are typically midline and paramedian, in the distribution of the perforating pontine branches.7 Conversely, primary traumatic brainstem hemorrhages most commonly occur in the pons, although they can have isolated medulla and midbrain involvement and there is less of a predilection for midline involvement.8

Observations

There have been several documented cases of Duret hemorrhage with neurological recovery in the literature (Table 1).5,6,9–11 Our case is unique, as the patient’s initial GCS score was 3 at the time of diagnosis, presumably shortly after trauma. There was substantial mass effect and midline shift of 1.3 cm and a protracted poor neurological examination for the initial 3 weeks before slow, spontaneous improvement. All other cases demonstrated gradual progressive improvements in function, and some had delayed neurological deterioration and with less mass effect (Table 1). Overall, while there are documented cases in the literature of neurological recovery after Duret hemorrhage, it remains a poorly studied phenomenon due to its rarity.

TABLE 1

Case reports of Duret hemorrhage with neurological improvement in the literature

Authors & YearAge (yrs)/SexClinical CourseDiagnosis of Duret HemorrhageNeurological Recovery
Stiver et al., 2009924/FRt EDH after an MVC, GCS 6, taken for urgent decompressive craniectomyOn postop scan 24 hrsGradual improvement in neurological exam on postop day 6; tracking & obeying 1 mo postop
Lonjaret et al., 20121021/MLt aSDH, GCS 3 w/lt blown pupil, taken for urgent lt craniectomyOn immediate postop scanGradual postop improvement; fully awake/alert 1 mo postop
Ishizaka et al., 2014658/MLt spontaneous SDH, GCS 4, taken for urgent lt craniotomyOn initial CTWalking independently 1 mo postop
Edlow et al., 20191126/MLt aSDH after a fall, initially GCS 15, nonoperative management w/dexamethasone; delayed deterioration 2 wks later necessitating craniectomy, followed by cranioplasty 2 mos laterOn MRI postop day 6Immediate postop improvement; obeying on postop day 3, speaking in short sentences
Nguyen et al., 2016537/MRt aSDH after a fall, taken to OR 3 days later after deterioration & pupillary changesOn CT 3 days after presentationObeying postop day 1

aSDH = acute SDH; EDH = epidural hematoma; MVC = motor vehicle collision; OR = operating room.

Lessons

Duret hemorrhage is a rare vascular phenomenon occurring in the aftermath of traumatic brain injury. Its radiographic presentation may be delayed and only seen on MRI. We demonstrate here that, even with an initially poor clinical examination, spontaneous clinically meaningful neurological recovery with supportive care is possible with a Duret hemorrhage. This could help guide the goals of care discussions and treatment decisions. This is also a single case report, limiting our ability to comment on the epidemiology or pathophysiology of this phenomenon.

Author Contributions

Conception and design: all authors. Acquisition of data: Pirouzmand, Ellenbogen. Analysis and interpretation of data: Pirouzmand. Drafting of the article: all authors. Critically revising the article: Pirouzmand, Ellenbogen. Reviewed submitted version of the manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Pirouzmand.

References

  • 1

    Lance S, Tan CH, Rosemergy I. The eyes have it: Duret haemorrhage after traumatic subdural haematoma. BMJ Case Rep. 2020;13(9):e237841.

  • 2

    Johnson PL, Eckard DA, Chason DP, Brecheisen MA, Batnitzky S. Imaging of acquired cerebral herniations. Neuroimaging Clin N Am. 2002;12(2):217228.

  • 3

    Parizel PM, Makkat S, Jorens PG, et al. Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage). Intensive Care Med. 2002;28(1):8588.

  • 4

    Walusinski O, Courrivaud P. Henry Duret (1849–1921): a surgeon and forgotten neurologist. Eur Neurol. 2014;72(3–4):193202.

  • 5

    Nguyen HS, Doan NB, Gelsomino MJ, Shabani S, Mueller WM. Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma. Int Med Case Rep J. 2016;9:1518.

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    • Search Google Scholar
    • Export Citation
  • 6

    Ishizaka S, Shimizu T, Ryu N. Dramatic recovery after severe descending transtentorial herniation-induced Duret haemorrhage: a case report and review of literature. Brain Inj. 2014;28(3):374377.

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    • Search Google Scholar
    • Export Citation
  • 7

    Kamijo Y, Soma K, Kishita R, Hamanaka S. Duret hemorrhage is not always suggestive of poor prognosis: a case of acute severe hyponatremia. Am J Emerg Med. 2005;23(7):908910.

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    • Search Google Scholar
    • Export Citation
  • 8

    Chen D, Tang Y, Nie H, et al. Primary brainstem hemorrhage: a review of prognostic factors and surgical management. Front Neurol. 2021;12:727962.

  • 9

    Stiver SI, Gean AD, Manley GT. Survival with good outcome after cerebral herniation and Duret hemorrhage caused by traumatic brain injury. J Neurosurg. 2009;110(6):12421246.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Lonjaret L, Ros M, Boetto S, Fourcade O, Geeraerts T. Brainstem hemorrhage following decompressive craniectomy. J Clin Neurosci. 2012;19(9):12931295.

  • 11

    Edlow BL, Threlkeld ZD, Fehnel KP, Bodien YG. Recovery of functional independence after traumatic transtentorial herniation with Duret hemorrhages. Front Neurol. 2019;10:1077.

    • PubMed
    • Search Google Scholar
    • Export Citation
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  • FIG. 1

    A: Axial head CT of a large acute SDH with midline shift. B: Axial head CT obtained 1 day postoperatively, demonstrating improved mass effect and satisfactory evacuation of the SDH. C: Axial CT of the same postoperative scan shown in panel B, demonstrating a pontine hyperdensity. D: Delayed head CT obtained on postoperative day 9, demonstrating stable pontine hypodensity.

  • FIG. 2

    A: Axial T1-weighted MRI demonstrating hypodensity in the pons consistent with Duret hemorrhage. B: Axial T2-weighted MRI demonstrating mixed hyperintensity/hypointensity in the pons consistent with Duret hemorrhage. C: Axial diffusion-weighted image demonstrating diffusion restriction of the mixed T2 hyperintense/hypointense lesion. D: Apparent diffusion coefficient axial MRI demonstrating reduced apparent diffusion coefficient signal over the previously seen diffusion-restricting lesion in panel C.

  • 1

    Lance S, Tan CH, Rosemergy I. The eyes have it: Duret haemorrhage after traumatic subdural haematoma. BMJ Case Rep. 2020;13(9):e237841.

  • 2

    Johnson PL, Eckard DA, Chason DP, Brecheisen MA, Batnitzky S. Imaging of acquired cerebral herniations. Neuroimaging Clin N Am. 2002;12(2):217228.

  • 3

    Parizel PM, Makkat S, Jorens PG, et al. Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage). Intensive Care Med. 2002;28(1):8588.

  • 4

    Walusinski O, Courrivaud P. Henry Duret (1849–1921): a surgeon and forgotten neurologist. Eur Neurol. 2014;72(3–4):193202.

  • 5

    Nguyen HS, Doan NB, Gelsomino MJ, Shabani S, Mueller WM. Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma. Int Med Case Rep J. 2016;9:1518.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Ishizaka S, Shimizu T, Ryu N. Dramatic recovery after severe descending transtentorial herniation-induced Duret haemorrhage: a case report and review of literature. Brain Inj. 2014;28(3):374377.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Kamijo Y, Soma K, Kishita R, Hamanaka S. Duret hemorrhage is not always suggestive of poor prognosis: a case of acute severe hyponatremia. Am J Emerg Med. 2005;23(7):908910.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Chen D, Tang Y, Nie H, et al. Primary brainstem hemorrhage: a review of prognostic factors and surgical management. Front Neurol. 2021;12:727962.

  • 9

    Stiver SI, Gean AD, Manley GT. Survival with good outcome after cerebral herniation and Duret hemorrhage caused by traumatic brain injury. J Neurosurg. 2009;110(6):12421246.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Lonjaret L, Ros M, Boetto S, Fourcade O, Geeraerts T. Brainstem hemorrhage following decompressive craniectomy. J Clin Neurosci. 2012;19(9):12931295.

  • 11

    Edlow BL, Threlkeld ZD, Fehnel KP, Bodien YG. Recovery of functional independence after traumatic transtentorial herniation with Duret hemorrhages. Front Neurol. 2019;10:1077.

    • PubMed
    • Search Google Scholar
    • Export Citation

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