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

Midline shift is a shift of the brain past its center line.[1] The sign may be evident on neuroimaging such as CT scanning.[1] The sign is considered ominous because it is commonly associated with a distortion of the brain stem that can cause serious dysfunction evidenced by abnormal posturing and failure of the pupils to constrict in response to light.[1] Midline shift is often associated with high intracranial pressure (ICP), which can be deadly.[1] In fact, midline shift is a measure of ICP; presence of the former is an indication of the latter.[2] Presence of midline shift is an indication for neurosurgeons to take measures to monitor and control ICP.[1] Immediate surgery may be indicated when there is a midline shift of over 5 mm.[3][4] The sign can be caused by conditions including traumatic brain injury,[1] stroke, hematoma, or birth deformity that leads to a raised intracranial pressure.

Methods of detection

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

Doctors detect midline shift using a variety of methods. The most prominent measurement is done by a computed tomography (CT) scan and the CT Gold Standard is the standardized operating procedure for detecting MLS.[5] Since the midline shift is often easily visible with a CT scan, the high precision of Magnetic Resonance Imaging (MRI) is not necessary, but can be used with equally adequate results.[5] Newer methods such as bedside sonography can be used with neurocritical patients who cannot undergo some scans due to their dependence on ventilators or other care apparatuses.[6] Sonography has proven satisfactory in the measurement of MLS, but is not expected to replace CT or MRI.[6] Automated measurement algorithms are used for exact recognition and precision in measurements from an initial CT scan.[7] A major benefit to using the automated recognition tools includes being able to measure even the most deformed brains because the method doesn’t depend on normal brain symmetry.[7] Also, it lessens the chance of human error by detecting MLS 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.[7]

Structures of the midline

[edit]

Three main structures are commonly investigated 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 ventricles.[7] It is easily found on CT or MRI images due to its unique hypodensity.[7] The other two important structures of the midline include the third ventricle and the pineal gland, which are both centrally located and caudal to the septum pellucidum.[6][7] Identifying the location of these structures on a damaged brain compared to an unaffected brain is another way of categorizing the severity of the midline shift. The terms mild, moderate, and severe are associated with the extent of increasing damage.

Midline shift in diagnoses

[edit]

Midline shift measurements and imaging has multiple applications. The severity of brain damage is determined by the magnitude of the change in symmetry. Another use is secondary screening to determine deviations in brain trauma at different times after a traumatic injury as well as initial shifts immediately after.[3] The severity of shift is directly proportional to the likeliness of surgery having to be performed. The degree of MLS can also be used to diagnose the pathology that caused it. The MLS measurement can be used to successfully distinguish between a variety of intracranial conditions including acute subdural hematoma,[5][7] malignant middle cerebral artery infarction,[3] epidural hematoma, subarachnoid hemorrhage, chronic subdural hematoma, infarction, intraventrical hemorrhage, a combination of these symptoms, or the absence of pertinent damage altogether.[7]

See also

[edit]

References

[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Midline shift

View on Grokipedia
from Grokipedia
Midline shift refers to the deviation of midline intracranial structures, such as the or , from their normal central position, typically resulting from caused by expanding lesions within the brain. This displacement is a critical radiological sign observed on computed (CT) or (MRI) scans, serving as an indicator of increased (ICP) and potential if untreated. It is commonly associated with acute conditions including , ischemic or hemorrhagic , brain tumors, and , where the shift reflects the severity of the underlying pathology and guides urgent clinical decision-making. The primary causes of midline shift involve intra-axial or extra-axial mass lesions that exert pressure on adjacent tissue, leading to lateral displacement of midline structures. Common etiologies include supratentorial hemorrhages (such as subdural or epidural hematomas), expansive tumors (e.g., gliomas or metastases), abscesses, and diffuse following trauma or , all of which can compress the and disrupt normal anatomy. In , for instance, midline shift correlates with the extent of from contusions or secondary swelling, while in , it often signals malignant requiring intervention. The shift can also occur paradoxically after drainage in certain cases, such as with skull defects, potentially worsening herniation risks. Clinically, midline shift is measured as the perpendicular distance in millimeters between a reference midline (often aligned with the ) and the displaced , typically at the level of the foramen of Monro on axial CT images. A shift greater than 5 mm is generally considered significant and is a strong predictor of poor outcomes, including mortality, with values exceeding 3.5 mm in showing up to 76% sensitivity for fatal . Shifts of this magnitude often necessitate emergent surgical management, such as or hematoma evacuation, to alleviate ICP and prevent brainstem compression. Conversely, smaller shifts under 5 mm may be monitored conservatively, particularly if the patient lacks focal neurological deficits, though serial imaging is essential to track progression. Automated detection algorithms, leveraging or landmark-based approaches on CT scans, are increasingly used to quantify shift accurately and aid in , with errors often below 1 mm compared to manual measurements.

Definition and Anatomy

Definition

Midline shift refers to the displacement of midline brain structures, such as the , , or , from their normal central position due to unequal , typically resulting from a mass effect caused by space-occupying lesions like hematomas or tumors. This deviation indicates a disruption in the brain's symmetrical architecture, where increased pressure on one side of the cranium pushes structures toward the contralateral side. Pathophysiologically, midline shift arises from the principles of the Monro-Kellie doctrine, which posits that the is a rigid container with a fixed volume occupied by brain tissue, blood, and cerebrospinal fluid; any mass lesion increases (ICP), leading to compression and displacement of adjacent structures. This can progress to syndromes, including subfalcine herniation (where the cingulate gyrus shifts under the ) or uncal herniation (involving the uncus of the ), potentially compressing the and causing irreversible neurological damage or death if untreated. The serves as a key reference point for assessing this shift, as its deviation highlights the extent of asymmetry. The concept of midline shift gained prominence in the era following the development of computed tomography (CT) in the 1970s, which allowed for precise visualization of intracranial displacements previously inferred from plain X-rays via pineal gland calcification shifts in trauma cases. Early recognition occurred in the context of severe , where CT scans revealed shifts correlating with poor outcomes. Clinically, midline shifts exceeding 5 mm are considered severe indicators of compromise, as classical studies have correlated such displacements with increased mortality and the need for urgent intervention, such as surgical evacuation of traumatic hematomas per Brain Trauma Foundation guidelines.

Midline Brain Structures

The midline brain structures serve as critical anatomical landmarks for evaluating brain symmetry and potential deviations. These include the , a thin triangular membrane composed of two layers of white and gray matter with sparse neuroglia, positioned between the anterior horns of the and attached to the inferior surface of the . The third ventricle, a narrow cleft in the , lies centrally between the thalami and hypothalami, connecting the via the foramina of Monro. The , a prominent dural fold of the , extends downward into the longitudinal fissure to separate the cerebral hemispheres. Posteriorly, the protrudes from the roof of the third ventricle, while the (aqueduct of Sylvius) forms a narrow channel traversing the to link the third and fourth ventricles. In normal anatomy, these structures exhibit symmetrical alignment along the , with the serving as a primary central reference point exhibiting zero deviation from the ideal midline on . The third ventricle and are similarly centered, flanked by bilateral thalami, ensuring balanced positioning relative to the , which anchors the hemispheres without lateral offset. The maintains a straight midline course through the tectum. Anatomical variations are uncommon and typically congenital, such as the , a persistent fluid-filled space between the membrane's leaflets that is present in the normal but fuses in over 85% of cases by 3-6 months of age, persisting in approximately 15% of adults as a benign finding. Other rare asymmetries, like mild deviations in ventricular size, do not constitute pathological shifts unless associated with . Displacement of these midline structures, particularly the , , or , signals the direction and magnitude of from intracranial , providing essential clues for severity assessment.

Causes

Traumatic Causes

Midline shift in the context of trauma most commonly results from severe , such as those sustained in accidents or falls, which produce focal mass lesions including epidural and subdural hematomas as well as cerebral contusions. Epidural hematomas, often arising from arterial bleeding due to skull fractures involving the , form a characteristic lens-shaped collection that rapidly expands and exerts significant . Subdural hematomas, by contrast, typically stem from rupture of bridging veins under acceleration-deceleration forces, leading to blood accumulation in the and progressive compression of adjacent brain tissue. Cerebral contusions involve direct parenchymal damage and associated , particularly in coup-contrecoup patterns, contributing to localized swelling that displaces midline structures. While primarily causes diffuse shearing without prominent , secondary in severe cases can occasionally exacerbate shift. The underlying mechanism involves the focal from hemorrhage or compressing the ipsilateral , which in turn pushes midline structures—such as the and —toward the contralateral side, often reducing the volume of the opposite lateral ventricle. This displacement reflects increased and potential for transtentorial herniation, particularly when shifts exceed 5 mm. In epidural hematomas, the rapid accumulation of blood due to high-pressure arterial sources amplifies this effect, whereas subdural hematomas may progress more insidiously but still induce contralateral deviation through venous bleeding and brain atrophy in vulnerable populations. Contusions further this process via cytotoxic and vasogenic formation at the site of impact. Midline shift >5 mm occurs in approximately 17% of cases with abnormal computed findings across large cohorts. The condition manifests with rapid onset, often within hours of the initial , driven by active bleeding or evolving , and can quickly advance to herniation syndromes if unmanaged. Detection on non-contrast CT typically reveals hyperdense lesions with associated shift, guiding urgent intervention.

Non-Traumatic Causes

Non-traumatic causes of midline shift typically arise from pathological processes that generate asymmetric mass effects within the brain, leading to displacement of midline structures without external mechanical injury. These conditions often develop more gradually than traumatic etiologies, allowing for potential intervention before severe herniation occurs. Primary examples include (ICH), where spontaneous bleeding into brain parenchyma creates a focal mass that expands over hours to days, exerting pressure on adjacent tissues and shifting the midline. Ischemic stroke, particularly large infarctions, can result in cytotoxic and vasogenic that peaks 3–5 days post-onset; space-occupying develops in up to 30% of such cases and often causes significant midline deviation. Brain tumors, such as gliomas or metastases, contribute to midline shift through progressive growth and associated peritumoral edema, often evolving over weeks and asymmetrically compressing the . Similarly, form encapsulated collections of from bacterial or fungal infections, generating localized mass effects that displace midline structures as they enlarge. , when obstructive and unilateral (e.g., due to ), leads to ventricular enlargement on one side, increasing (ICP) asymmetrically and causing gradual midline shift. The underlying mechanisms in these non-traumatic scenarios involve either direct mass expansion—such as growth in ICH or tumor proliferation—or secondary formation that elevates ICP unevenly across hemispheres, prompting brain tissue to shift toward the contralateral side over extended periods, typically days to weeks. Unlike rapid shifts from trauma, this slower progression permits monitoring of evolving displacement via serial imaging, though untreated cases can still culminate in herniation. Special cases encompass metabolic derangements, such as in advanced , where from ammonia toxicity may produce mild midline shifts alongside elevated ICP. Infectious processes like can induce focal inflammation and , particularly in temporal lobes, resulting in measurable midline deviation. Iatrogenic factors, including post-surgical after tumor resection or , may also cause transient shifts due to or residual mass effects. Epidemiologically, non-traumatic midline shift is more prevalent in older adults, reflecting the higher incidence of underlying conditions like hypertension-related ICH and ischemic strokes; these shifts correlate with poorer outcomes due to comorbidities.

Detection and Measurement

Imaging Modalities

Non-contrast computed tomography (CT) scanning serves as the gold standard for visualizing midline shift in acute settings, such as , due to its rapid acquisition time, widespread availability in emergency departments, and ability to detect associated acute hemorrhages and fractures. This modality effectively delineates key midline structures, including the and , allowing for prompt assessment in unstable patients. Magnetic resonance imaging (MRI) offers an alternative for evaluating midline shift, particularly in subacute or non-traumatic cases, providing superior soft tissue contrast to identify , ischemia, or mass effects not as readily apparent on CT. However, MRI is limited by longer scan times, which make it less suitable for hemodynamically unstable patients, and contraindications such as implanted pacemakers or ferromagnetic objects. Ultrasound, performed bedside, enables midline shift detection in specific populations, such as infants through open fontanelles or unstable patients requiring non-transportable , using transfontanelle or transcranial approaches to visualize ventricular shifts. Its advantages include no and real-time capability, but it is restricted by poor acoustic windows in adults due to skull and limited penetration beyond infancy. Emerging automated AI-based tools integrated with CT scans facilitate rapid midline shift detection and initial quantification, processing images in seconds with reported accuracies exceeding 95% in validation studies from the 2020s, enhancing efficiency in high-volume settings. These systems, often employing for landmark identification, reduce inter-observer variability but require further standardization across diverse pathologies. General limitations across modalities include CT's ionizing radiation exposure, particularly concerning in pediatric or repeated imaging scenarios, and the overall need for specialized equipment and expertise.

Measurement Techniques

The standard method for quantifying midline shift entails measuring the perpendicular distance from the to the ideal midline on an axial computed (CT) slice, typically at the level of the foramen of Monro, with the ideal midline positioned midway between the inner tables of the . This approach ensures a consistent reference for assessing displacement caused by . For cases involving posterior shifts, alternative landmarks such as the or may be employed to better capture deviation in those regions. The magnitude of the shift is then calculated using the formula: Shift (mm)=∣actual position−expected midline∣\text{Shift (mm)} = |\text{actual position} - \text{expected midline}| where the actual position refers to the observed location of the landmark relative to the expected midline position. Inter-observer variability in these manual measurements is generally low, ranging from 0.5 to 1.0 mm on CT scans, but can be further minimized through three-dimensional (3D) reconstructions, which provide enhanced spatial accuracy and reduce subjective discrepancies in landmark identification. In the Marshall classification for , a midline shift of 0-5 mm corresponds to diffuse injury II, while >5 mm indicates diffuse injury III. A shift ≥5 mm is generally considered clinically significant and may indicate the need for surgical intervention. Recent advances incorporate volumetric analysis via specialized software, such as , which automates midline shift quantification and integrates it with complementary metrics like herniation indices to offer a more holistic evaluation of .

Clinical Significance

Diagnostic Applications

Midline shift serves as a critical diagnostic marker in (TBI), where it quantifies the from lesions such as , aiding in the of patients for surgical intervention. A shift exceeding 5 mm on computed tomography (CT) is considered significant and often indicates the need for urgent evacuation of the hematoma to mitigate rising and prevent herniation. This threshold is incorporated into prognostic scoring systems like the Rotterdam CT score, which evaluates midline shift alongside other features such as basal cistern effacement to stratify TBI severity and guide transfer to specialized trauma centers. In ischemic stroke and brain tumors, midline shift helps differentiate unilateral from bilateral pathology by revealing asymmetric displacement of midline structures, such as the , away from the affected hemisphere in cases of focal from or . For instance, in large hemispheric infarctions, a shift greater than 5 mm within the hours signals malignant expansion, prompting serial imaging to track progression and identify candidates for decompressive procedures. This distinction is particularly valuable in tumors, where unilateral shift correlates with primary lesions exerting localized pressure, contrasting with more symmetric involvement in diffuse processes. Midline shift also contributes to differential diagnosis by confirming structural brain pathology in patients presenting with nonspecific symptoms, such as severe headaches mimicking migraines, where its presence on imaging rules out functional causes and points to mass lesions or hemorrhage. It integrates with clinical signs of elevated , including Cushing's triad (, , and irregular respiration), to corroborate the and urgency of underlying conditions like acute or . These applications are embedded in established guidelines, such as the American Association for the Surgery of Trauma (AAST)-endorsed best practices via the Trauma Quality Improvement Program, which utilize midline shift in scoring for TBI management. Similarly, the 2021 European Stroke Organisation (ESO) guidelines for space-occupying infarctions incorporate midline shift assessment. Recent literature as of emphasizes AI-assisted imaging tools to automate detection and enhance diagnostic accuracy in acute settings.

Prognostic Indicators

The degree of midline shift serves as a key prognostic indicator in patients with (TBI), with shifts exceeding 5 mm strongly associated with increased mortality and poor functional outcomes. A midline shift of ≥5 mm on initial computed tomography (CT) imaging has been linked to an of 13.77 (95% CI: 1.54–123.49) for in-hospital mortality, reflecting significant risk amplification compared to lesser shifts. Shifts of 1-5 mm correlate with approximately 70-80% favorable outcomes at 6 months, while those of 6–10 mm yield favorable rates of 35–64% at 1–6 months post-injury, underscoring a dose-dependent worsening of . Shifts greater than 10 mm, particularly approaching 15 mm, further elevate mortality risk and diminish neurological recovery potential. Midline shift heightens the of cerebral herniation syndromes, which can lead to life-threatening brainstem compression and associated clinical signs such as decerebrate posturing and fixed dilated pupils. In subfalcine herniation, a midline shift exceeding 5 mm indicates substantial , with deviations over 15 mm portending a particularly prognosis due to progressive compression of vital structures. This herniation risk contributes to secondary , exacerbating ischemia and overall morbidity in affected hemispheres. Prognostic implications are modified by the rate of midline shift progression, which often portends worse outcomes than a static alone; for instance, maximal shifts exceeding 2.35 mm within 48 hours post-intervention predict poor recovery. When combined with elevated (ICP) above 20 mmHg, midline shift amplifies mortality and morbidity risks, as the duo signals uncontrolled and potential for rapid decompensation. Long-term recovery is guided by serial imaging assessments of midline shift, where minimal residual shifts under 2 mm post-treatment align with improved Outcome Scale (GOS) scores, indicating better functional independence at 6–12 months. Persistent or recurrent shifts beyond this threshold correlate with unfavorable GOS categories (1–3), highlighting the value of ongoing monitoring for outcome prediction.

Management

Monitoring Approaches

Monitoring midline shift in hospitalized patients typically involves serial imaging to detect dynamic changes in brain structure, particularly in acute settings such as (TBI) or (ICH). Non-contrast computed tomography (CT) scans are the cornerstone, repeated every 6 to 12 hours in unstable patients to assess progression of and shift, allowing timely intervention before herniation. In chronic or less acute cases, (MRI) may supplement CT for detailed evaluation of subtle shifts, though its use is limited by longer acquisition times in intensive care units (ICUs). This approach follows initial detection via baseline CT, providing a comparative framework for ongoing surveillance. Non-invasive tools play a key role in frequent, bedside assessment without radiation exposure. Intracranial pressure (ICP) monitoring, often via intraventricular catheters or parenchymal probes, indirectly tracks midline shift through pressure trends, as elevated ICP frequently correlates with mass effect and structural displacement in severe TBI. Parenchymal monitors are particularly suitable in cases with existing midline shift, avoiding risks associated with catheter placement in distorted anatomy. Ultrasound measurement of optic nerve sheath diameter (ONSD) serves as a proxy for ICP and midline shift, with diameters exceeding 5.5 mm indicating significant shift in TBI patients, offering a rapid, repeatable non-invasive option at the bedside. Neurocritical care protocols emphasize structured surveillance based on shift severity. The American Heart Association/American Stroke Association 2022 guidelines for ICH recommend prompt repeat CT imaging upon neurological deterioration and routine serial CT at approximately 6 and 24 hours post-onset in stable patients to monitor including midline shift. For TBI, the Brain Trauma Foundation guidelines advocate ICP monitoring and repeat imaging in patients with abnormal CT findings, such as shift greater than 5 mm. These protocols integrate clinical exams with imaging to balance resource use and in ICUs. Technological aids enhance precision and efficiency in monitoring. Automated AI algorithms for midline shift quantification from CT scans, such as those measuring displacement at the , enable rapid analysis and real-time alerts in ICUs, reducing inter-observer variability. Emerging tools like portable MRI further support continuous low-field imaging for shift assessment without patient transport, integrating with AI for trend detection in critical care settings.

Treatment Interventions

Treatment of midline shift primarily focuses on addressing the underlying cause while reducing (ICP) to reverse the shift and prevent herniation. Medical management is often the initial approach for patients with mild to moderate shifts, particularly in cases of elevated ICP. Hyperosmolar therapy, such as administered at a dose of 0.5–1 g/kg intravenously, creates an osmotic gradient to draw fluid from tissue, thereby reducing and associated midline shift. Hypertonic saline serves as an alternative or adjunct, providing similar ICP reduction with potentially more sustained effects in (TBI) settings. is employed as a temporizing measure to induce , leading to cerebral and transient ICP lowering, though it is recommended for short durations to avoid ischemia. For midline shift due to peritumoral , corticosteroids like dexamethasone are used to decrease vasogenic , improving neurological symptoms and shift on imaging. Surgical interventions are indicated for significant midline shifts, typically exceeding 5 mm, especially when accompanied by clinical deterioration or refractory ICP. Craniotomy allows for evacuation of mass lesions such as hematomas, directly alleviating the compressive force causing the shift. involves removing a large portion of the to permit expansion, effectively reducing midline shift and ICP in severe cases like malignant or TBI with swelling. This procedure has been shown to improve and six-month survival in patients with massive hemispheric . For ICH-related midline shift, minimally invasive endoscopic evacuation may improve functional outcomes in select patients with large hematomas, as shown in trials as of 2024. Cause-specific treatments target the etiology of the shift. In contributing to midline deviation, ventriculoperitoneal shunting diverts to normalize ventricular size and pressure. For neoplastic causes, surgical resection of the tumor mass is the primary intervention to relieve compression, often followed by to control residual disease and prevent recurrence. Early surgical evacuation of lesions such as acute in eligible TBI patients is associated with better functional outcomes compared to delayed treatment. Decisions for escalation, such as proceeding to , may be triggered by worsening shift on serial imaging.

References

  1. https://pmc.ncbi.nlm.nih.gov/articles/PMC5925103/
  2. https://radiopaedia.org/articles/midline-shift
  3. https://www.ahajournals.org/doi/10.1161/STROKEAHA.117.016733
  4. https://pmc.ncbi.nlm.nih.gov/articles/PMC10539714/
  5. https://www.acr.org/Data-Science-and-Informatics/AI-in-Your-Practice/AI-Use-Cases/Use-Cases/Midline-Shift
  6. https://pmc.ncbi.nlm.nih.gov/articles/PMC7871460/
  7. https://www.kenhub.com/en/library/anatomy/septum-pellucidum
  8. https://www.aans.org/patients/conditions-treatments/anatomy-of-the-brain/
  9. https://mayfieldclinic.com/pe-anatbrain.htm
  10. https://www.ncbi.nlm.nih.gov/books/NBK532932/
  11. https://radiopaedia.org/articles/cavum-septum-pellucidum-3?lang=us
  12. https://www.sciencedirect.com/topics/neuroscience/midline-shift
  13. https://www.ncbi.nlm.nih.gov/books/NBK557861/
  14. https://www.ncbi.nlm.nih.gov/books/NBK518982/
  15. https://www.ncbi.nlm.nih.gov/books/NBK532970/
  16. https://www.ncbi.nlm.nih.gov/books/NBK448102/
  17. https://pmc.ncbi.nlm.nih.gov/articles/PMC7461333/
  18. https://www.ncbi.nlm.nih.gov/books/NBK553103/
  19. https://pmc.ncbi.nlm.nih.gov/articles/PMC11065061/
  20. https://www.sciencedirect.com/topics/medicine-and-dentistry/midline-shift
  21. https://pmc.ncbi.nlm.nih.gov/articles/PMC2797474/
  22. https://www.ncbi.nlm.nih.gov/books/NBK482119/
  23. https://link.springer.com/article/10.1007/s11940-014-0297-2
  24. https://www.ncbi.nlm.nih.gov/books/NBK557643/
  25. https://onlinelibrary.wiley.com/doi/full/10.1002/ams2.260
  26. https://pubmed.ncbi.nlm.nih.gov/34494212/
  27. https://pmc.ncbi.nlm.nih.gov/articles/PMC8870205/
  28. https://www.qure.ai/evidence/automated-detection-of-midline-shift-and-mass-effect-from-head-ct-scans-using-deep-learning
  29. https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0043-1777676.pdf
  30. https://radiopaedia.org/articles/midline-shift?lang=us
  31. https://onlinelibrary.wiley.com/doi/10.1155/2018/4303161
  32. https://www.facs.org/media/vgfgjpfk/best-practices-guidelines-traumatic-brain-injury.pdf
  33. https://www.ahajournals.org/doi/10.1161/01.str.0000441965.15164.d6
  34. https://pmc.ncbi.nlm.nih.gov/articles/PMC5330994/
  35. https://www.ncbi.nlm.nih.gov/books/NBK549801/
  36. https://pmc.ncbi.nlm.nih.gov/articles/PMC8370077/
  37. https://insightsimaging.springeropen.com/articles/10.1186/s13244-024-01723-7
  38. https://pmc.ncbi.nlm.nih.gov/articles/PMC10037627/
  39. https://thejns.org/view/journals/j-neurosurg/131/2/article-p596.xml
  40. https://pubmed.ncbi.nlm.nih.gov/38030746/
  41. https://pmc.ncbi.nlm.nih.gov/articles/PMC4852589/
  42. https://journals.lww.com/neur/fulltext/2023/71060/assessment_of_midline_shift_in_postdecompressive.9.aspx
  43. https://www.sciencedirect.com/science/article/pii/S1878747923015507
  44. https://www.ncbi.nlm.nih.gov/books/NBK542298/
  45. https://www.jtraumainj.org/journal/view.php?number=915
  46. https://www.ahajournals.org/doi/10.1161/STR.0000000000000407
  47. https://www.nature.com/articles/s41598-021-03892-7
  48. https://pmc.ncbi.nlm.nih.gov/articles/PMC11659353/
  49. https://pmc.ncbi.nlm.nih.gov/articles/PMC7272487/
  50. https://pmc.ncbi.nlm.nih.gov/articles/PMC12406498/
  51. https://pmc.ncbi.nlm.nih.gov/articles/PMC5747306/
  52. https://pmc.ncbi.nlm.nih.gov/articles/PMC5066438/
  53. https://pmc.ncbi.nlm.nih.gov/articles/PMC7595803/
  54. https://jamanetwork.com/journals/jamaneurology/fullarticle/2838201
  55. https://pmc.ncbi.nlm.nih.gov/articles/PMC7379019/
  56. https://pmc.ncbi.nlm.nih.gov/articles/PMC3628720/
  57. https://pubmed.ncbi.nlm.nih.gov/19960231/
  58. https://pmc.ncbi.nlm.nih.gov/articles/PMC4250331/
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