J Korean Neurosurg Soc.  2022 Sep;65(5):652-664. 10.3340/jkns.2022.0002.

The Kernohan-Woltman Notch Phenomenon : A Systematic Review of Clinical and Radiologic Presentation, Surgical Management, and Functional Prognosis

• Beucler N
• Cungi PJ
• Baucher G
• Coze S
• Dagain A
• Roche PH

• KMID: 2533028
• DOI: http://doi.org/10.3340/jkns.2022.0002

Abstract

The Kernohan-Woltman notch phenomenon (KWNP) refers to an intracranial lesion causing massive side-to-side mass effect which leads to compression of the contralateral cerebral peduncle against the free edge of the cerebellar tentorium. Diagnosis is based on “paradoxical” motor deficit ipsilateral to the lesion associated with radiologic evidence of damage to the contralateral cerebral peduncle. To date, there is scarce evidence regarding KWNP associated neuroimaging patterns and motor function prognostic factors. A systematic review was conducted on Medline database from inception to July 2021 looking for English-language articles concerning KWNP, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The research yielded 45 articles for a total of 51 patients. The mean age was 40.7 years-old and the male/female sex ratio was 2/1. 63% of the patients (32/51) suffered from head trauma with a majority of acute subdural hematomas (57%, 29/51). 57% (29/51) of the patients were in the coma upon admission and 47% (24/51) presented pupil anomalies. KWNP presented the neuroimaging features of compression ischemic stroke located in the contralateral cerebral peduncle, with edema in the surrounding structures and sometimes compression stroke of the cerebral arteries passing nearby. 45% of the patients (23/51) presented a good motor functional outcome; nevertheless, no predisposing factor was identified. A Glasgow coma scale (GCS) of more than 3 showed a trend (p=0.1065) toward a better motor functional outcome. The KWNP is a regional compression syndrome oftentimes caused by sudden and massive uncal herniation and leading to contralateral cerebral peduncle ischemia. Even though patients suffering from KWNP usually present a good overall recovery, patients with a GCS of 3 may present a worse motor functional outcome. In order to better understand this syndrome, future studies will have to focus on more personalized criteria such as individual variation of tentorial notch width.

Keyword

Head trauma; Acute subdural hematoma; Mydriasis; Hemiplegia; Kernohan

Figure

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  Fig. 1. Medline based systematic review on Kernohan-Woltman notch phenomenon. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. Adopted from Moher et al. [38].

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  Fig. 2. Typical features of Kernohan-Woltman notch phenomenon on brain magnetic resonance imaging (MRI). A and B : T2-weighted MRI shows hyperintensity in the left cerebral peduncle facing the tentorial notch (courtesy of Simonin et al. [50]). C : MRI in fluid-attenuated inversion recovery sequence displays hyperintensity in the left cerebral peduncle (white arrow) (courtesy of Yogarajah et al. [60]). D : MRI diffusion-weighted imaging displays hyperintensity in the right cerebral peduncle (white arrow) (courtesy of Chang [7]). E : T2-weighted MRI 2 years after injury displays white matter hyperintensity in the substantia nigra of the left cerebral peduncle (black arrowhead) (courtesy of Ueda et al.[53]). F : MRI in diffusion tensor imaging with tractography displays interruption of the right corticospinal tract 8 weeks after injury (courtesy of Jang and Pyun [28]). G : Ioflupane (123I) single photon emission computed tomography (DatSCAN™ SPECT) 2 years after trauma shows a reduced dopamine transporter-specific tracer uptake in the left striata (for credits see E).

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  Fig. 3. Artistic view of Kernohan-Woltman notch phenomenon caused by a right-sided acute subdural hematoma in coronal (left illustration) and axial view (right illustration). Please note the interruption of the contralateral corticospinal tract (green) because of direct compression against the free edge of the cerebellar tentorium. The posterior cerebral artery is compressed between the herniated temporal uncus (red arrowhead) and the midbrain, and the superior cerebellar artery between the cerebral peduncle and the inferior face of the tentorium (purple arrowhead). In axial view, ipsilateral CN III is stretched by the brainstem displacement. Nathan BEUCLER is the corresponding author of this article and certifies that he is the artist who performed the drawings illustrated in Fig. 3. The authorization to publish this Figure is provided as Supplementary Table 1. PCA : posterior cerebral artery, SCA : superior cerebellar artery, CN II : second cranial nerve, optic nerve, ACP : anterior clinoid process, CN III : third cranial nerve, oculomotor nerve.

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