Uncus

Clinical significance

• Seizures, often preceded by hallucinations of disagreeable odors, often originate in the uncus.
• In situations of tumor, hemorrhage, or edema, increased pressure within the cranial cavity, especially if the mass is in the middle fossa, can push the uncus over the tentorial notch against the brainstem and its corresponding cranial nerves and can result in a brain herniation. If the uncus becomes herniated the structure lying just medial to it, cranial nerve III, can become compressed. This causes problems associated with a non-functional or problematic CN III - the pupil on the ipsilateral side fails to constrict to light and absence of medial/superior movement of the orbit, resulting in a fixed, dilated pupil and an eye with a characteristic "down and out" position due to dominance of the abducens and trochlear nerves. Further pressure on the midbrain results in progressive lethargy, coma and death due to compression of the mesencephalic reticular activating system. Brainstem damage is typically ipsilateral to the herniation, although the contralateral cerebral peduncle may be pushed against the tentorial notch, resulting in a characteristic indentation known as Kernohan's notch and ipsilateral hemiparesis, since fibers running in the cerebral peduncle decussate in the lower medulla to control muscle groups on the opposite side of the body.

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