Treatment of Uncal Herniation
The immediate treatment for uncal herniation requires aggressive intervention with mannitol or hypertonic saline, hyperventilation, head elevation, and urgent neurosurgical decompression to prevent mortality and improve neurological outcomes. 1, 2
Initial Management
Immediate Interventions
- Airway management: Immediate endotracheal intubation for patients with Grade III-IV encephalopathy 1
- Head positioning: Elevate head 20-30° to facilitate venous drainage and reduce ICP 1, 2
- Hyperosmolar therapy:
Ventilation Management
- Hyperventilation: Target PaCO₂ of 30-35 mmHg (not less than 4 kPa) for short-term use only 1, 2
- Oxygenation: Maintain PaO₂ ≥ 13 kPa 1
- PEEP: Minimum 5 cmH₂O to prevent atelectasis 1
Pharmacological Management
Hyperosmolar Agents
- Mannitol:
- Mechanism: Increases plasma osmolarity, drawing water from brain tissue to reduce edema 3
- Dosing: Initial 0.5-1 g/kg IV, may repeat every 4-6 hours as needed 2
- Monitoring: Maintain serum osmolality <320 mOsm/L 2
- Contraindications: Severe renal disease, congestive heart failure, active intracranial hemorrhage 2
Sedation and Seizure Management
- Sedation: Appropriate sedation and analgesia via continuous infusion 1
- Seizure control: Treat with phenytoin and low-dose benzodiazepines 1
- For refractory ICP: Consider short-acting barbiturates 1, 2
Surgical Management
Indications for Surgical Intervention
- Failure of medical management to control ICP
- Progressive neurological deterioration
- Radiological evidence of significant mass effect
Surgical Options
- Decompressive craniectomy: For large hemispheric strokes with malignant edema 1
- Temporal lobectomy: May be considered in traumatic subdural hematoma with uncal herniation 4
- CSF drainage: Via ventriculostomy in appropriate cases 2
Monitoring
Clinical Monitoring
- Frequent neurological assessments (pupillary size and response)
- Vital signs including blood pressure targets
- Signs of progressive herniation
Laboratory Monitoring
- Electrolytes every 4-6 hours
- Renal function
- Serum osmolality
Special Considerations
Fluid Management
- Use isotonic fluids (0.9% saline) to maintain hydration 1
- Avoid hypotonic solutions (Ringer's lactate, Ringer's acetate) 1
- Avoid albumin or synthetic colloids in brain injury 1
Blood Pressure Management
- Maintain adequate cerebral perfusion pressure (60-70 mmHg) 2
- Treat hypertension with increased sedation and small boluses of labetalol 1
- Treat hypotension (after correcting hypovolemia) with α-agonists 1
Prognosis
The outcome of uncal herniation depends primarily on:
- Speed of intervention
- Initial Glasgow Coma Scale score (highly significant predictor) 5
- Underlying cause of herniation
- Presence of complications
Research indicates that uncal herniation is not necessarily fatal and may be reversible with prompt and appropriate interventions 5.
Common Pitfalls to Avoid
- Prolonged hyperventilation: Can cause cerebral ischemia; use only for short-term management 1
- Prophylactic hyperventilation: Not recommended in patients with acute liver failure 1
- Corticosteroids: Should not be used to control elevated ICP 1
- Delayed neurosurgical consultation: Should be sought early to facilitate planning of decompressive surgery 1
- Inadequate monitoring: Patients require close observation for signs of deterioration 2