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Transtentorial herniation (TTH) is defined as the downward displacement of medial brain structures through the tentorial notch due to increased intracranial pressure after brain injury.1 Impaired consciousness, induced by compression of the ascending reticular activation system (ARAS) in the brainstem, is a common clinical manifestation of TTH.1 Recently, diffusion tensor tractography (DTT), derived from diffusion tensor imaging (DTI), has enabled three-dimensional reconstruction and estimation of the lower portion of the ARAS in normal participants.2 ,3 However, little is known about injury of the ARAS by TTH following brain injury.
In the current study, using DTT, we report on a patient with injury in the lower portion of the ARAS due to TTH following an intracerebral haemorrhage (ICH).
A 73-year-old female patient was coma mental state when she arrived in the emergency room of a university hospital. The Glasgow Coma Scale (GCS) score was 5/15 (eye opening 1, best verbal response 1 and best motor response 3). She was diagnosed with spontaneous ICH in the right frontotemporal lobe. Brain CT at the onset of ICH showed a right-to-left midline shift with TTH due to the large haematoma in the right frontotemporal lobes (figure 1A). Brain MRI taken at 1 month after onset showed that the haematoma had resolved and no significant injury was observed in the brainstem, except for both cerebral peduncles (figure 1A). However, …