Brain Herniation

Nursing Knowledge

Brain Herniation

Brain herniation is an often fatal medical emergency where brain tissue is moved by increased intracranial pressure, potentially compressing vital structures like the respiratory or cardiac centers. Recognizing early signs and symptoms is essential for prompt intervention to prevent irreversible damage.
Last updated: June 28, 2024

Table of contents

What is brain herniation? 


Brain herniation occurs when pressure inside the skull pushes brain tissue into abnormal spaces. 

Brain herniation is a medical emergency and often fatal, with a low survival rate if not treated immediately.


Brain herniation is most often caused by swelling or bleeding due to: 

  • Head injury
  • Stroke
  • Brain tumor 

Types of brain herniation

The types of brain herniation can be differentiated by the location of the herniation: 

  • Uncal: uncus (innermost part of the temporal lobe) pushed down over the tentorium
  • Central (transtentorial): brain’s central structures pushed downward through the tentorial notch
  • Cingulate (subfalcine): cingulate gyrus displaced under the falx cerebri
  • Transcalvarial: brain tissue getting pushed through a defect in the skull
    • Upward cerebellar (transtentorial)
    • Downward cerebellar (tonsillar) 

Stages of brain herniation

The progression of brain herniation can be classified as follows: 

  1. Initial stage: increased intracranial pressure without significant brain tissue shift
  2. Early herniation: beginning of tissue displacement, with altered consciousness and mild neurological deficits
  3. Late herniation: severe tissue shift, significant neurological impairment, and potential brainstem compression
  4. Terminal stage: irreversible brain damage and failure of brainstem functions

Brain herniation symptoms and signs 

  • Increased intracranial pressure (ICP)
  • Changes in pupils: asymmetry, dilated, pinpoint, or no movement
  • Bradycardia
  • ↑ BP initially, ↓ BP in later stages
  • Irregular breathing
  • Severe headache
  • Weakness
  • Cardiac and respiratory arrest
  • Coma
  • Loss of brainstem activity

Herniation can cause brain death due to irreversible brain stem dysfunction or damage to the brain’s respiratory and cardiovascular centers, causing respiratory or cardiac arrest. 

Affected persons may exhibit the symptoms of the Cushing’s triad indicating increased intracranial pressure: hypertension, bradycardia, and irregular breathing. 

Brain herniation treatment and nursing care tasks


The goal when treating brain herniation is to reduce swelling and pressure. 


  • Endotracheal intubation
  • Hyperventilation with ICP and CO2 monitoring 
  • Fluid management
  • Drain for CSF based on elevation and parameters of order
  • Surgery to remove clot, tumor
  • Craniectomy
  • Diuretics 
  • BP control
  • Therapeutic hypothermia
  • Induced coma

Nursing care tasks

  • Elevate head of the bed to 30°, keep a neutral neck position
  • Monitoring:
    • Vital signs: BP, temperature, pain
    • Intracranial pressure
    • I&O assessment
    • Neuro status assessment 
  • Follow orders for sedation and pain medication
  • DVT and ulcer prophylaxis

Family education

Inform the family that the client’s prognosis is affected by multiple factors, including 

  • Client age
  • Location, type and duration of herniation
  • Concurrent trauma

Provide emotional support and resources for families during the acute and rehabilitation phases.


Brain Herniation

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Overview of causes, symptoms, treatment, nursing care, and family education for clients with brain herniation.

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