Kernohan's notch and misdiagnosis of disorders of consciousness

BMJ Case Rep. 2014 Feb 17:2014:bcr2013202094. doi: 10.1136/bcr-2013-202094.

Abstract

A 69-year-old man presented with a sudden headache followed by unconsciousness. There was no head injury. The Glasgow Coma Scale (GCS) score was 3/15 and there was a left mydriasis, unreactive to light. The CT-scan showed a left acute subdural haematoma causing a remarkable mass effect. A supratentorial hemispheric craniotomy was performed. Nevertheless, after several weeks at the intensive care unit (ICU), the patient was still unresponsive to external stimuli and did not show any motor activity. A comfort care attitude was decided on with the family and the patient was extubated. However, a few days later, the patient subsequently showed a surprisingly favourable course, with improved wakefulness. Indeed, the GCS score improved, and the treatment plan was modified so that the patient benefited from rehabilitation. The MRI showed a right cerebral peduncle lesion, consistent with a Kernohan-Woltman notch phenomenon (KWNP). Six months later, the patient was able to walk and live quite normally.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Anisocoria / etiology
  • Craniotomy
  • Diagnostic Errors*
  • Hematoma, Subdural, Acute / complications
  • Hematoma, Subdural, Acute / diagnosis*
  • Hemiplegia / etiology
  • Humans
  • Magnetic Resonance Imaging
  • Male
  • Mydriasis / etiology
  • Tegmentum Mesencephali / pathology*
  • Tomography, X-Ray Computed
  • Unconsciousness / diagnosis*
  • Unconsciousness / etiology