Table 4 Comparison of the uncal andcentral herniation syndromes

Uncal Herniation Syndrome

Central Herniation Syndrome

Ipsilateral 3rd nerve palsy (dilated, poorly reactive pupil, often laterally and inferiorly deviated)

Contralateral hemiparesis (face and arm, greater than leg weakness)

Decorticate (flexor posturing of arms), or decerebrate posturing (extensor posturing of arms and legs)

Decreased level of consciousness or coma

Decreased level of consciousness


Progression from purposeful motor activity (pushing examiner away), to avoidance (withdrawing from painful stimulus), to decorticate posturing, to decerebrate posturing

Bilateral loss of pupillary reactivity and or extraocular movements (midbrain level)

Eventual brain death

Ocular bobbing and pinpoint pupils, absent corneal reflexes (pontine level)

Loss of vestibulo-ocular reflex ('doll's eyes') and cold-water caloric reflex (low pontine level)

Loss of spontaneous respiratory drive and gag reflex (medullary level)

Brain death

may undergo expectant management with close observation. When surgery is necessary, great care must be taken to avoid venous air embolism and uncontrolled bleeding from torn sinuses.

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