Upward cerebellar herniation

This occurs with large or superior cerebellar masses and produces a clinical picture which is indistinguishable from the central herniation syndrome. With progressive crowding of the tentorial notch, the pineal gland and suprapineal recess are displaced superiorly and the superior cerebellar and posterior cerebral arteries may be compressed against the free margins of the tentorium. This can lead to ischemic infarction of the superior cerebellum and occipital lobes which further complicates matters. If the precipitating lesion has not already obstructed the flow of cerebrospinal fluid, upward herniation of the cerebellum will often do so at the level of the aqueduct of Sylvius. This produces a counterbalancing effect in which the tentorial notch is invaded from below by the herniating cerebellum and from above by the descending temporal lobes (Fig 3). The combination is invariably fatal unless immediate decompression of both the supra- and infratentorial compartments is provided.

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