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Tentorial Coup Injury to the Brain Stem

Published online by Cambridge University Press:  20 October 2014

Young-Do Kim  and
Tae-Won Kim
Young-Do Kim
Affiliation:
Department of Neurology, Catholic University of Korea, Incheon St’s Mary’s Hospital, Incheon, Korea
Tae-Won Kim*
Affiliation:
Department of Neurology, Catholic University of Korea, Incheon St’s Mary’s Hospital, Incheon, Korea
*
Correspondence to: Tae-Won Kim, Department of Neurology, Incheon St’s Mary’s Hospital, Catholic University of Korea, 665 Bupyeong-6-dong, Bupyeong-gu, Incheon, 403-720, Korea. Email: kimtaewon79@gmail.com
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Abstract

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Type
Neuroimaging Highlight
Information
Canadian Journal of Neurological Sciences , Volume 41 , Issue 5 , September 2014 , pp. 650
Copyright
Copyright © The Canadian Journal of Neurological Sciences Inc. 2014 

A 38-year-old man, with a history of a closed head injury from a motor vehicle collision one month prior, presented with sustained headache and dizziness. Neurologic examination was unremarkable except for provoked rotational nystagmus beating towards the left during Dix-Hallpike test on the left side. Post-traumatic benign paroxysmal positional vertigo was diagnosed. T2-weighted magnetic resonance imaging (MRI) demonstrated abnormal bright signal intensities involving the right lateral midbrain (Figure). On T2-weighted coronal MRI, this lesion was closely relating to or touching the tentorial notch at the level of the midbrain. Based on the images, the mechanism of midbrain injury in our patient was speculated to be due to tentorial coup injury.

Figure Axial fluid-attenuated inversion recovery image. (a) demonstrates abnormal bright signal involving the right lateral midbrain. Coronal T2-weighted images (b) demonstrates the corresponding bright signal lesion (arrow) at the level of the midbrain closely relating to or touching the tentorial notch (dashed arrow).

Tentorial coup injury is known to be caused by lateral displacement of the brain stem against the tentorium. The clinical manifestations are variable, depending on the anatomical location of injury. Sensory deficits, long tract signs as well as cerebellar and cranial nerve palsy have been reported.Reference Sei Ki and Higuchi 1 It is also suggested that brief loss of consciousness in concussion could be possibly explained by tentorial coup injury through the transmission of kinetic energy to the median raphe and reticular core in midbrain.Reference Adler and Milhorat 2

The distance between tentorial notch and brain stem ranges from zero to five mm. The short distance between them makes the lateral brainstem vulnerable to injury from even minor closed head injuries in some cases.Reference Saeki, Yamamura and Sunami 3 Therefore, tentorial coup injury is not rare in patients with severe head injuryReference Britt, Herrick and Mason 4 and it can also occur in patients with minor head trauma in whom the distance between them is relatively short.Reference Sei Ki and Higuchi 1 , Reference Saeki, Yamamura and Sunami 3

References

1. Sei Ki, N, Higuchi, Y. Selective hemihypaesthesia due to tentorial coup injury against dorsolateral midbrain: potential cause of sensory impairment after closed head injury. J Neurol Neurosurg Psychiatry. 2000;68:117-118.Google Scholar
2. Adler, DE, Milhorat, TH. The tentorial notch: anatomical variation, morphometric analysis, and classification in 100 human autopsy cases. J Neurosurg. 2002;96(6):1103-1112.Google Scholar
3. Saeki, N, Yamamura, A, Sunami, K. Brain stem contusion due to tentorial coup injury: case report and pathomechanical analysis from normal cadavers. Br J Neurosurg. 1998;12(2):151-155.Google Scholar
4. Britt, RH, Herrick, MK, Mason, RT, et al. Traumatic lesions of pontomedullary junction. Neurosurgery. 1980;6(6):623-631.Google Scholar
Figure 0

Figure Axial fluid-attenuated inversion recovery image. (a) demonstrates abnormal bright signal involving the right lateral midbrain. Coronal T2-weighted images (b) demonstrates the corresponding bright signal lesion (arrow) at the level of the midbrain closely relating to or touching the tentorial notch (dashed arrow).