It’s interesting how technical skills get so much attention, but the ability to stay calm, organized, and clear-headed under pressure can completely change an outcome. In paramedical work, confidence isn’t just about knowing the steps, it’s about executing them when things aren’t going smoothly. What’s one mindset or habit that’s helped you maintain clarity in challenging situatio ns?”

Brain herniation is one of the most time-critical neurological emergencies we face. It doesn’t shout at the beginning, it whispers. But when it declares itself, deterioration can be rapid, dramatic, and irreversible. Understanding the early signs, the mechanisms, and the clinical patterns is essential for anyone working in acute, critical, or emergency care. 🔍 What Is Brain Herniation? Brain herniation occurs when rising intracranial pressure (ICP) forces brain tissue to shift from its normal position into adjacent compartments. This displacement compresses vital structures, including the brainstem and threatens cerebral perfusion. In simple terms: 👉 Too much pressure → not enough space → the brain is pushed somewhere it shouldn’t be. This can be fatal within minutes if not recognised. 🧠 The Main Types of Brain Herniation Here are the key herniation patterns you need to know: 1️⃣ Uncal (Transtentorial) Herniation The medial temporal lobe is pushed under the tentorium. Key features: Unilateral fixed, dilated pupil (CN III compression) Ptosis and “down and out” eye position Reduced level of consciousness Contralateral motor weakness → progressing to hemiplegia Late: Cushing’s triad (hypertension, bradycardia, irregular respirations) Think: Pupil change = uncal herniation until proven otherwise 2️⃣ Central Herniation Downward shift of the diencephalon and brainstem. Early signs: Subtle changes in consciousness Small, reactive pupils Respiratory pattern changes Decorticate posturing Late signs: Fixed pupils Flexor → extensor posturing changes Cushing’s triad Think: A progressive decline with bilateral signs. 3️⃣ Subfalcine Herniation Cingulate gyrus shifts beneath the falx cerebri. Signs may be subtle: Headache Altered mentation Weakness in one leg (compression of ACA territory) Often an early warning before more dangerous herniation patterns occur. 4️⃣ Tonsillar Herniation The cerebellar tonsils are forced down through the foramen magnum. This is immediately life-threatening.