Treatments for Cerebellar Tonsillar Herniation

The prototypical case of brain herniation through the foramen magnum is tonsillar
herniation. In tonsillar herniation, parts of the cerebellum are forced downward through the
foramen magnum by increased intracranial pressure and they proceed to put a disruptive pressure
on the medulla oblongota and proximal cervical spinal cord.
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Treatment plans for all brain herniations are similar in that they target the root of the
problem: the increased intracranial pressure. The major tactics to achieve this are:
1. Treat the underlying cause of the raised intracranial pressure (e.g. give antibiotics for
meningitis, resect the causal tumor, remove a blood clot, etc.)
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2. Remove any lesion, such asn a hematoma, abcess, or tumor, causing the increase in ICP
3. Give osmotic therapy (mannitol, lasix, hypertonic saline) to pull fluid out of the brain
tissue and reduce the pressure
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4. Take steps to minimize cerebral edema:
a. Maintain adequate cerebral oxygenation to minimize vasodilatation
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b. Maintain blood pressure to ensure end-organ perfusion and to increase
vasoconstriction. Recommended levels are Cerebral Perfusion Pressure (CPP)
(Mean Arterial Pressure (MAP) Intracranial Pressuren (ICP)) greater than or
equal to 60 mm Hg.
1
Allowing hypotension in the patient is bad! It will cause
reactive vasodilation in the brain and actually increase intracranial pressure.
Too high of a degree of hypertension can also be detrimental, so treatment of
hypertension should be pursued if CPP >120 mmHg and ICP >20 mmHg
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c. Induce mild hyperventilation to increase vasoconstriction
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d. Intubation as required to avoid hypercapnia which leads to vasodilatation
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e. Position the patient at 30 degrees to increase venous drainage
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f. Sedate the patient to decrease cerebral metabolism
4

g. Glucocorticoids may be useful, but only in cases of elevated ICP due to tumors
or CNS infections. Even in those cases, it is controversial.
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h. Seizure control to decrease cerebral metabolism and avoid further trauma
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5. Ventricuolostomy, a procedure to drain the CSF from the ventricules via shunts, is
especially effective in cases of hydrocephaly due to intraventricular blood.
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Hydoencephaly due to blockades in the CSF communicating pathway can also be
corrected by shunting procedures.
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6. Decompressive craniectomy, a procedure in which part of the skull is removed to allow
a swelling brain room to expand without being squeezed, should only be performed in
extreme cases when other recourses are impossible or too slow to affect results.
8
It is a
controversial procedure with questionable efficacy.
In the case of Mr. Middleton, antibiotics should be given for suspected meningitis.
Osmotherapy (mannitol and/or hypertonic saline) should be started to reduce ICP. His blood
pressure should be monitored and maintained such that his CPP remains between 60 and 120
mmHg. He should be given barbituates to reduce his cranial metabolism and oxygen
supplementation to avoid vasodilation. He should be positioned at 30 to improve venous
drainage from his head.

Sources:
1. Halliday, A. Cerebral Herniation Syndromes. [PowerPoint]. La Crosse, OR: Oregon
Neurosurgery Specialists; 2012.
2. Paczynski RP. Osmotherapy. Basic concepts and controversies. Crit Care Clin 1997;
13:105.
3. Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol
and clinical results. J Neurosurg 1995; 83:949.
4. Lafferty JJ, Keykhah MM, Shapiro HM, et al. Cerebral hypometabolism obtained with
deep pentobarbital anesthesia and hypothermia (30 C). Anesthesiology 1978; 49:159.
5. Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death
within 14 days in 10008 adults with clinically significant head injury (MRC CRASH
trial): randomised placebo-controlled trial. Lancet 2004; 364:1321.
6. Lassen NA. Control of cerebral circulation in health and disease. Circ Res 1974; 34:749.
7. Procaccio F, Stocchetti N, Citerio G, et al. Guidelines for the treatment of adults with
severe head trauma (part I). Initial assessment; evaluation and pre-hospital treatment;
current criteria for hospital admission; systemic and cerebral monitoring. J Neurosurg Sci
2000; 44:1.
8. Moody RA, Ruamsuke S, Mullan SF. An evaluation of decompression in experimental
head injury. J Neurosurg 1968; 29:586.