Midline shift

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Midline shift (arrow) is present in this brain after a stroke (infarct depicted in shaded area).

This subdural hematoma/epidural hematoma (arrows) is causing midline shift of the brain

Midline shift is a shift of the brain past its center line. !" The sign may be e#ident on neuroimaging such as $T scanning. !" The sign is considered ominous because it is commonly associated with a distortion of the brain stem that can cause serious dysfunction e#idenced by abnormal posturing and failure of the pupils to constrict in response to light. !" Midline shift is often associated with high intracranial pressure (%$&), which can be deadly. !" %n fact, midline shift is a measure of %$&' presence of the former is an indication of the latter.
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&resence of midline shift is an indication for neurosurgeons to take measures to monitor and control %$&. %mmediate surgery may be indicated when there is a midline shift of o#er ) mm. *" +" The sign can be caused

by conditions including traumatic brain in,ury, !"stroke, hematoma, or birth deformity that leads to a raised intracranial pressure.

Methods of Detection -octors detect midline shift using a #ariety of methods. The most prominent measurement is done by a computed tomography ($T) scan and the $T .old /tandard is the standardi0ed operating procedure for detecting M1/. )" /ince the midline shift is often easily #isible with a $T scan, the high precision of Magnetic 2esonance %maging (M2%) is not necessary, but can be used with e3ually ade3uate results. )" 4ewer methods such as bedside sonography can be used with neurocritical patients who cannot undergo some scans due to their dependence on #entilators or other care apparatuses. 5" /onography has pro#en satisfactory in the measurement of M1/, but is not e6pected to replace $T or M2%. 5" 7utomated measurement algorithms are used for e6act recognition and precision in measurements from an initial $T scan. 8" 7 ma,or benefit to using the automated recognition tools includes being able to measure e#en the most deformed brains because the method doesn9t depend on normal brain symmetry. 8" 7lso, it lessens the chance of human error by detecting M1/ from an entire image set compared to selecting the single most important slice, which allows the computer to do the work that was once manually done. 8" Structures of the Midline Three main structures are commonly in#estigated when measuring midline shift. The most important of these is the septum pellucidum, which is a thin and linear layer of tissue located between the right and left #entricles. 8" %t is easily found on $T or M2% images due to its uni3ue hypodensity. 8" The other two important structures of the midline include the third #entricle and the pineal gland which are both centrally located and caudal to the septum pellucidum. 5" 8" %dentifying the location of these structures on a damaged brains compared to an unaffected brain is another way of categori0ing the se#erity of the midline shift. The terms mild, moderate, and se#ere are associated with the e6tent of increasing damage. Midline Shift in Diagnoses Midline shift measurements and imaging has multiple applications. The se#erity of brain damage is determined by the magnitude of the change in symmetry. 7nother use is secondary screening to determine de#iations in brain trauma at different times after a traumatic in,ury as well as initial shifts immediately after. *" The se#erity of shift is directly proportional to the likeliness of surgery ha#ing to be performed. M1/ also has the aptitude to diagnoses the #ery pathology that caused it. The M1/ measurement can be used to successfully distinguish between a #ariety of intracranial conditions including acute subdermal hematoma, )" 8" malignant middle cerebral artery infarction, *" epidural hematoma, subarachnoid hemorrhage, chronic subdermal hematoma, infarction, intra#entrical hemorrhage, a combination of these symptoms, or the absence of pertinent damage altogether. 8"