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Sequence of signs with progressive cerebral herniation

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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The idealized sequence of physical signs, with progressive cerebral herniation, is described below:

  • diencephalic stage:
    • confused and drowsy
    • constricted pupils
    • gaze palsies

  • mesencephalic stage:
    • unconscious
    • decerebrate posturing
    • dilated pupils
    • hyperventilation

  • pontine stage:
    • unconscious
    • decerebrate posturing
    • constricted pupils
    • irregular breathing

  • medullary stage:
    • unconscious
    • flaccid
    • loss of homeostatic control:
      • increase heart rate
      • decrease blood pressure
      • hyperthermia
    • Cheyne-Stokes breathing
  • apnoea and cardiac arrest

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