Encephalic Herniation Syndromes: Clinico-Radiological and Neuroanatomical Integration in Stratification and Neurosurgical Management – A Narrative Review

Abstract

Encephalic herniation syndromes represent a neurocritical condition resulting from the decompensation of intracranial dynamics, characterized by the displacement of brain structures across rigid compartments, leading to compression of vital regions and a high risk of mortality. They are associated with intracerebral hemorrhage, traumatic brain injury, and metabolic disorders, with intracranial hypertension and cerebral edema being the main underlying mechanisms. The objective of this study was to perform a narrative literature review, emphasizing the clinico-radiological and neuroanatomical integration of these syndromes, aiming to contribute to risk stratification and neurosurgical management. The methodology consisted of a search for articles in the PubMed/MEDLINE, Scopus, and Web of Science databases, using descriptors related to encephalic herniation, intracranial hypertension, cerebral edema, neuroimaging, and neurosurgery. Studies published between 2020 and 2026 with free full text were included, and nine articles were selected after applying eligibility criteria. The results showed that the volume of expansive lesions and midline shift strongly correlate with the risk of herniation and allow prognostic stratification. Different herniation patterns are associated with specific clinical manifestations, reflecting the involvement of distinct neuroanatomical structures. The integrated analysis highlighted the central role of neuroimaging in early identification and therapeutic decision-making. It is concluded that the integration of clinical, radiological, and neuroanatomical data is essential for early diagnosis, risk stratification, and appropriate management of these syndromes, with a direct impact on reducing mortality.