Kernohan notch phenomenon

Kernohan notch phenomenon is an imaging finding resulting from extensive midline shift due to mass effect, resulting in indentation in the contralateral cerebral crus by the tentorium cerebelli. This has also been referred to as Kernohan-Woltman notch phenomenon and false localising sign.

The integrity of the crus cerebri and its descending corticospinal tracts is disturbed, and a contralateral (to crus cerebri) motor deficit is produced with a deteriorating level of consciousness. A hemiparesis ipsilateral to the expanding mass is known as Kernohan phenomenon, which is a false localising sign.

Transtentorial herniation is a well-described neurologic phenomenon caused by an expanding supratentorial mass/lesion. Uncal herniation is a common subtype of transtentorial herniation in which the innermost part of the temporal lobe, the uncus, can be squeezed so much that it goes by the tentorium and puts pressure on the brainstem, most notably the midbrain.

Compressive forces cause the cerebral peduncle of the midbrain to impinge on the contralateral edge of the tentorium cerebelli, forming an indentation in the crus known as Kernohan's notch. With time, the integrity of the crus cerebri and its descending corticospinal tracts is disturbed, and a contralateral (to crus cerebri) motor deficit is produced with a deteriorating level of consciousness.

Radiographic features

Kernohan notch is demonstrated on cross-sectional imaging of the brain and is best seen in the coronal plane.

CT

On CT it is usually possible to show the mass effect of a tumour on the brain stem, but identification of an uncal herniation is much harder with CT.

MRI

MRI with its ability to image the brain in multiple planes and excellent resolution of the brainstem can reveal a deformity or injury of the cerebral peduncle resulting from a transtentorial herniation.

History and etymology

The phenomenon was first described by James Watson Kernohan, born 1897, Irish-born American pathologist in 1929 after an autopsy study revealed a notched cerebral peduncle from a contralateral herniation syndrome.

Diagnosing Kernohan-Woltman notch phenomenon by somatosensory evoked potentials in intensive care unit ¹⁾.

A 29-year-old male patient post right-sided traumatic brain injury presenting with persistent ipsilateral hemiparesis. Patient underwent decompressive craniotomy and intracranial hematoma evacuation. Brain magnetic resonance imaging in the postoperative period showed a subtle lesion in the left cerebral peduncle. PET/CT was performed to exclude early brain tumor and explain his ipsilateral hemiparesis. PET/CT imaging demonstrated a focal region of intense 18 F-FDG uptake in the left cerebral peduncle. Throughout the treatment in outpatient neurorehabilitation unit, the patient exhibited a gradual recovery of his right hemiparesis.

For the first time, PET/CT offered microstructural and functional confirmation of KWNP. Moreover, our case suggests that 18 F-FDG PET/CT may serve as an important reference for the probability of functional recovery ²⁾.