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Images in Neurology
February 2002

Uncal Herniation in Acute Subdural Hematoma: Point of No Return

Arch Neurol. 2002;59(2):305. doi:10.1001/archneur.59.2.305

A 71-YEAR-OLD man fell from his rocking chair and the next day developed headache and a rapid decrease in responsiveness. He had received anticoagulant medication following placement of a metallic aortic valve. On arrival to our institution, he was in extremis, with a Glasgow Coma Scale score of 3. He had been intubated and, due to a minimal respiratory effort, he was placed on full mechanical ventilation. Both pupils were fixed in midposition (5 mm), and oculocephalic responses and corneal reflexes were absent. Minimal cough could be elicited. Spontaneous triple flexion responses were noted. His computed tomography scan showed subdural hematoma with massive brain shift, uncal herniation, and brainstem ("Duret") hemorrhages (Figure 1).1 His international normalized ratio on admission was 1.6.

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