Secondary (Duret) brainstem haemorrhage may not always represent a fatal event Review of literature and report of four cases

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Martin Hanko
Branislav Kolarovszki
Kristián Varga
René Opšenák
Pavol Snopko
Radoslav Hanzel
Kamil Zeleňák

Abstract

Background. Secondary brainstem haemorrhage (eponymously called Duret haemorrhage) is a well-known complication of transtentorial brain herniation or of rapid decompression of intracranial space. It is considered to be a consequence of arterial rupture, venous infarction or ischemia-reperfusion injury and it is regarded as a harbinger of an unfavourable outcome for the patient. Despite this, several case reports describing good outcome after Duret haemorrhage preceded by evacuation of an expansive traumatic intracranial mass lesion, an episode of intracranial hypotension or lumbar drainage have been published.
Case description. We present four cases of patients with secondary brainstem haemorrhage linked to an episode of intracranial hypertension due to various reasons who were treated at our clinic. The first patient suffered a small brainstem haemorrhage that was described on his initial CT scan presumably as a result of massive intracranial expansion caused by an acute subdural haematoma and this Duret haemorrhage markedly expanded after the subdural haematoma was evacuated by means of a decompressive craniectomy. The next two patients developed Duret haemorrhage after the evacuation of intracranial haematomas. The fourth patient presented with posttraumatic cerebral oedema complicated by a subtle Duret haemorrhage displayed on his initial CT scan and this bleeding remained stable even after a bilateral decompressive craniectomy. One patient passed away, one remained in a persistent coma and two survived with a light neurological deficit.
Conclusions. However ominous a newly discovered Duret haemorrhage may be, it alone should not discourage us from the further intensive treatment of our patients as their outcome may considerably vary. The extent of this bleeding, type and severity of underlying brain injury and complete clinical status and history of our patients should all be taken into account when deciding about patients’ prognosis.

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How to Cite
Hanko, M., Kolarovszki, B., Varga, K., Opšenák, R., Snopko, P., Hanzel, R., & Zeleňák, K. (2019). Secondary (Duret) brainstem haemorrhage may not always represent a fatal event. Romanian Neurosurgery, 33(2), 166-173. https://doi.org/10.33962/roneuro-2019-031
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Author Biographies

Martin Hanko

MD. Clinic of Neurosurgery, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SLOVAKIA

Branislav Kolarovszki

Assoc. Professor. MD. PhD. Clinic of Neurosurgery, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SLOVAKIA

Kristián Varga

MD. Clinic of Neurosurgery, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SLOVAKIA

René Opšenák

MD. PhD. Clinic of Neurosurgery, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SLOVAKIA

Pavol Snopko

MD. Clinic of Neurosurgery, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SLOVAKIA

Radoslav Hanzel

MD. Clinic of Neurosurgery, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SLOVAKIA

Kamil Zeleňák

Assoc. Professor. MD, PhD, FCIRSE. Clinic of Radiology, University Hospital in Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, SLOVAKIA