Duret Brainstem Hemorrhage After Transtentorial Descending Brain Herniation: A Systematic Review and Meta-Analysis

-BACKGROUND.: Historically, the occurrence of hemorrhage in the brainstem after an episode of supratentorial intracranial hypertension was described by Henri Duret in 1878. Nevertheless, to date the eponym Duret brainstem hemor-rhage (DBH) lacks systematic evidence regarding its epidemiology, pathophys-iology, clinical and radiologic presentation, and outcome.-METHODS: We conducted a systematic literature review and meta-analysis using the Medline database from inception to 2022 looking for English -language articles concerning DBH, in accordance with the PRISMA guidelines.-RESULTS: The research yielded 28 articles for 32 patients (mean age, 50 years; male/female ratio, 3:1). Of patients, 41% had head trauma causing 63% of sub-dural hematoma, responsible for coma in 78% and mydriasis in 69%. DBH appeared on the emergency imaging in 41% and on delayed imaging in 56%. DBH was located in the midbrain in 41% of the patients, and in the upper middle pons in 56%. DBH was caused by sudden downward displacement of the upper brainstem secondary to supratentorial intracranial hypertension (91%), intra-cranial hypotension (6%), or mechanical traction (3%). Such downward displacement caused the rupture of basilar artery perforators. Brainstem focal symptoms (P = 0.003) and decompressive craniectomy (P = 0.164) were po-tential favorable prognostic factors, whereas an age >50 years showed a trend toward a poor prognosis (P = 0.0731).-CONCLUSIONS: Unlike its historical description, DBH appears as a focal hematoma in the upper brainstem caused by the rupture of anteromedial basilar artery perforators after sudden downward displacement of the brainstem, regardless of its cause.

Automated summary

DBH is a hemorrhage in the brainstem caused by sudden downward displacement of the brainstem after an episode of increased intracranial pressure. The systematic literature review and meta-analysis revealed the limited evidence on the epidemiology, pathophysiology, clinical presentation, and outcome of DBH.