Presentation
Two days after the diagnosis of meningitis, the patient presents with uncontrolled convulsions, a deterioration in level of consciousness, irregular respiration, and a coma.
Patient Data
Diffuse swelling and edema of cerebral hemispheres which appears hyperintense on the T2/FLAIR sequences, shows restricted diffusion on the DWI/ADC, and causes effacement of the sulci and CSF cisterns.
Areas of T1 hyperintense signal corresponding to blooming artifact in T2* sequences denote blood signal intensity in bifrontal and right parietal lobes.
Midline shift to the left with subfalcine herniation.
Transtentorial herniation, right uncal herniation (medial part of the right temporal lobe protrudes through the tentorium, the temporal horn of the right lateral ventricle is trapped), protrudes into the four ventricle, severely compressing the brainstem.
Inferior descent of cerebellar tonsils into the foramen magnum.
Crescentic right subdural collection with blood signal intensity.
Case Discussion
Most subtypes of brain herniations occur in this case; subfalcine, transtentorial, uncal, and tonsillar. This causes mass effect severely compressing the brainstem and cervico-medullary junction.
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