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A 52-year-old woman with no significant past medical history presents with a headache and a subsequent fall without loss of consciousness. Over the next few days, the patient continued to have headaches of increasing intensity. On the day of admission, she complained of a particularly severe headache, which preceded another fall. It was at this time that the patient was brought to a nearby emergency department (ED), where a computerized tomographic (CT) scan of the head revealed a large space-occupying lesion, which was likely a parafalcine meningioma. The patient soon developed a seizure and then became obtunded, with newly documented pupillary asymmetry. After receiving mannitol, the patient was transferred to a neurologic ICU for further intervention.

On arrival at the neurologic intensive care unit (NICU), the patient was intubated with eyes closed and unable to follow commands. The right pupil was 5 mm and nonreactive, while the left pupil was 3 mm and reactive; corneal and gag reflexes were intact. The patient was able to briskly localize with the right arm and leg, while the left arm and leg were flexing to painful stimuli. Vital signs on admission were temperature of 99.7°F, HR 91 bpm in sinus rhythm, blood pressure of 120/67 mm Hg by cuff reading, and mechanical ventilation set to assist control–volume control.

What should be the first step in managing this patient?

This patient is clearly demonstrating clinical signs of herniation. The comatose examination with loss of airway protection requiring mechanical ventilation as well as the neurologic signs such as dilation and loss of reactivity of the right pupil and flexor posturing of the left arm/leg are strong indicators that the patient is suffering from right-sided brainstem compression. This constellation of neurologic signs is the most concerning issue in this patient's presentation and, as such, requires the most immediate attention from the treating physician.

A stat CT of the head (Figure 8-1) will demonstrate location of the mass, extent of midline shift, edema, hydrocephalus, lesional (with possible intraventricular) hemorrhage, and type of herniation. In this case, a large (5.5 × 5.6 × 5.7 cm), calcified, hyperdense mass is noted along the superior anterior falx associated with moderate surrounding edema and causing mass effect upon the right greater than left frontal horns. There is no associated hemorrhage or hydrocephalus. There is loss of sulcation indicative of elevated intracranial pressure (ICP), as well as acute infarcts in the bilateral occipital lobes, right greater than left, suggesting an ongoing process of transtentorial (uncal) herniation.

Figure 8-1.

(Left) Noncontrast head CT revealing the large, midline hyperdense mass with calcifications along the anterior falx. Also noted is associated edema, bilateral compression of the frontal horns (right greater than left), and loss of sulcation suggestive of elevated ICP. (Right) Crowding of the ambient cisterns with medial displacement of the R temporal horn suggestive of downward (uncal) herniation. There are ...

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