In what type of hernia is Crushing's triad typically present?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: August 21, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Cushing's Triad is Present in Transtentorial (Uncal) Herniation

Cushing's triad (hypertension, bradycardia, and irregular respiration) is characteristic of transtentorial herniation, specifically uncal herniation, where increased intracranial pressure causes compression of the brainstem.

Pathophysiology of Transtentorial Herniation

Transtentorial herniation occurs when brain tissue is displaced through the tentorial notch due to increased intracranial pressure. This can happen in two main forms:

  1. Uncal (lateral) herniation:

    • The uncus of the temporal lobe is pushed medially and downward through the tentorial notch
    • Compresses the midbrain and oculomotor nerve (CN III)
    • Leads to Cushing's triad as a response to brainstem compression

  2. Central (downward) herniation:

    • Downward displacement of the diencephalon and midbrain through the tentorial notch
    • Often occurs with diffuse cerebral edema or large supratentorial masses

Clinical Manifestations of Transtentorial Herniation

Cushing's Triad

  • Hypertension: Systolic blood pressure increases as a compensatory mechanism to maintain cerebral perfusion
  • Bradycardia: Parasympathetic response to increased intracranial pressure
  • Irregular respiration: Due to compression of respiratory centers in the brainstem

Other Clinical Signs

  • Pupillary dilation (initially unilateral) due to CN III compression
  • Decreased level of consciousness
  • Hemiparesis (often contralateral)
  • Decerebrate or decorticate posturing
  • Cheyne-Stokes respiration or other abnormal breathing patterns

Differential Diagnosis

It's important to distinguish transtentorial herniation from other types of brain herniation:

  • Subfalcine herniation: Cingulate gyrus herniates under the falx cerebri
  • Tonsillar herniation: Cerebellar tonsils herniate through the foramen magnum
  • Upward transtentorial herniation: Cerebellar tissue herniates upward through the tentorial notch
  • Transcalvarial herniation: Brain tissue herniates through a skull defect

Management Considerations

The presence of Cushing's triad indicates a neurosurgical emergency requiring immediate intervention to reduce intracranial pressure:

  1. Immediate measures:

    • Elevate head of bed to 30 degrees
    • Hyperventilation (temporarily)
    • Mannitol or hypertonic saline administration
    • Neurosurgical consultation

  2. Definitive treatment:

    • Surgical decompression
    • Evacuation of mass lesion if present
    • Management of underlying cause (tumor, hemorrhage, etc.)

Common Pitfalls

  • Cushing's triad may not be present in all cases of transtentorial herniation
  • Bradycardia may be a late finding; tachycardia can occur in early stages
  • Misinterpreting Cushing's triad as indicating cardiac or respiratory pathology rather than increased intracranial pressure
  • Delaying neurosurgical intervention while pursuing other diagnostic studies

Early recognition of Cushing's triad and prompt intervention are critical for preventing irreversible brain damage and death in patients with transtentorial herniation.

Related Questions

What is the most likely diagnosis for a patient with chronic constipation, abdominal distension, vomiting, and a tender non-reducible swelling in the right groin, with X-ray findings of a distended small bowel and multiple fluid levels?
What are the clinical findings for femoral hernia obstruction?
What are the symptoms of hernia strangulation?
How should a firm abdomen with hernia and purple discoloration be managed?
What is the proper decision for a patient with severe abdominal pain, distension, constipation, and radiating pain to the right thigh and knee, 10 years after bariatric surgery (bariatric surgery) with significant weight loss?
Is jugular compression a recognized condition and which specialists treat it?
What is the treatment for a hamstring injury with a full thickness tear and retraction of the semimembranosus tendon?
What is the treatment for campylobacter (Campylobacter) gastroenteritis in pediatrics?
Does the timing of prednisone (corticosteroid) intake affect Natural Killer (NK) cell test results?
What are the primary concerns and management strategies for complications of campylobacter (Campylobacter) gastroenteritis in pediatric patients?
What are the treatment options for hyperkalemia?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question