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Background
Classically, in uncal herniation, clinical features include ipsilateral pupil mydriasis and contralateral hemiparesis. 1
However, a supratentorial space-occupying lesion can compress the contralateral corticospinal tract in the cerebral peduncle against the tentorium notch, causing a motor deficit ipsilaterally. Kernohan and Woltman described this phenomenon in 1929. 2 They performed a postmortem examination of subjects with hemiparesis ipsilateral to a brain tumour. They thought that a hemispheric mass lesion could compress the contralateral crus cerebri against the tentorial notch. This is now called the Kernohan-Woltman notch phenomenon (KWNP). 3
KWNP is a cause of false localising neurological signs, creating a neurological deficit ipsilaterally to the lesion, and defying the corticospinal decussation principles. 4
We describe a case of unilateral acute subdural haematoma, in which both ipsilateral and contralateral corticospinal tracts were affected. Despite early surgery, the patient did not show any sign of consciousness postoperatively. Nor did he exhibit any motor response. This contributed to a misdiagnosis of the real state of consciousness and rehabilitation potential.
Case presentation
A 69-year-old healthy man presented with a sudden onset of headache followed by unconsciousness. There was no head injury. The Glasgow Coma Scale (GCS) score was 3/15 and there was a left anisocoria, unreactive to light. The patient was intubated and transferred to the hospital by helicopter. The CT scan performed on admission ( figure 1 ) showed a left acute subdural haematoma causing a remarkable mass effect. The CT-angiogram was negative for vascular abnormalities. A supratentorial hemisphebric craniotomy was performed and an intraparenchymal intracranial pressure (ICP) monitor was inserted.
Postoperatively, the patient was transferred to the intensive care unit (ICU). The CT-scan performed 24 h after surgery was satisfactory, and ICP values were in the 15-20 mm Hg range. After 10 days at the ICU, there was still no contact with the patient, who was intubated with spontaneous respiration. Eyes were open but there was neither eye movement nor fixation. There was a skew deviation, anisocoria (left reactive mydriasis), slightly diminished left corneal reflex and blinking on noise. He was grimacing on pain stimulation, but no motor activity was present. The Coma Recovery Scale-R score was at 6/23, corresponding to a minimal conscious state minus (MCS-). An EEG was performed, showing reactive waveforms, without signs of...