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Images in Neurology |

Kernohan-Woltman Notch Phenomenon in Acute Subdural Hematoma

Patrick J. Codd, MD1; Pankaj K. Agarwalla, MD1; John Berry-Candelario, MD, MPH1; Brian V. Nahed, MD1
[+] Author Affiliations
1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
JAMA Neurol. 2013;70(9):1194-1195. doi:10.1001/2013.jamaneurol.54.
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A 52-year-old right-handed woman with a history of alcohol abuse presented to our institution several hours after she fell approximately 1.5 m (5 ft) from a bed and hit the right side of her head. Her family had noted a progressive right facial droop and right-sided weakness, which prompted her immediate transfer to our institution for further management.

On admission, she was noted to be somnolent but arousable, demonstrating confused speech. Both of her pupils were briskly reactive, but her right eye movements were limited, except for a lateral gaze consistent with a partial third nerve palsy. She had a noticeable forehead-sparing right facial droop, and her right-sided strength was notably 4−/5. She maintained full strength on the left side of her body and had brisk localization to painful stimuli in all extremities. Computed tomographic imaging revealed an acute subdural hematoma approximately 15 mm in maximal thickness, 12 mm of midline shift, and right-sided uncal herniation (Figure 1).

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Figure 1.
Computed Tomographic Scan of the Brain of a 52-Year-Old Woman

The computed tomographic scan without a contrast agent reveals a large right-sided acute subdural hematoma with significant right-to-left midline shift (black arrows).

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Figure 2.
Magnetic Resonance Imaging Scan of the Brain of a 52-Year-Old Woman

Magnetic resonance imaging was performed without a contrast agent after subdural hematoma evacuation. Diffusion-weighted imaging (A) and apparent diffusion coefficient (B) sequences were obtained that demonstrate a focal region of restricted diffusion with the left cerebral peduncle (white arrows).

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