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Neurology India, Vol. 59, No. 2, March-April, 2011, pp. 322 Correspondence Bilateral transtentorial herniation and isolated fourth ventricle: A scientific note Suhas Udayakumaran Department of Neurosurgery, Amrita Institute of Medical Sciences, Ponekkara P.O, Kochi- 682041, India Correspondence Address: Suhas Udayakumaran, Department of Neurosurgery, Amrita Institute of Medical Sciences, Ponekkara P.O, Kochi- 682041, India, dr.suhas@gmail.com Date of Submission: 12-Jan-2011 Code Number: ni11097 PMID: 21483156 DOI: 10.4103/0028-3886.79166 Sir, We read with interest the letter to the editor by Novak et al. [1] and congratulate them for highlighting a rare clinical entity. The authors suggested that to the best of their knowledge their case was probably the first description of this rare phenomenon. They have been regretfully incomplete in their literature search, especially the most recent publications by our group. [2],[3],[4] Transtentorial uncal herniation, in its chronic form, has been reported in only a few case reports with some unclear clinical implications. We had described this rare finding in 2 children, secondary to 2 diverse etiologies: as a sequela of a posterior fossa shunt ( secondary to shunt overdrainage) [3] and as a developmental association (secondary to CSF loss through the open spinal defect) with a Chiari II malformation. [4] We proposed a unified hypothesis that this phenomenon of chronic uncal herniation can be due to the pressure gradient that develops between supratentorial compartment and the infratentorial compartment. [2] The patient reported by these authors had posterior fossa shunt and bilateral transtentorial herniation of chronic nature ("living patient"), thus supporting our postulation. The management strategies suggested by us include [3],[4] : (1) ruling out shunt malfunction in cases of simultaneous presence of supratentorial ventriculoperitoneal shunt; (2) upgrading the valve of the infratentorial shunt in situations otherwise when overdrainage is suspected; and (3) careful follow-up whenever in asymptomatic patients. References
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