Potential Kernohan’s Notch Phenomenon in a Patient with Ipsilateral Hemiplegia and Associated Dysphagia and Visual Deficits Following Parafalcine Subdural Hemorrhage: A Case Report

Case Diagnosis: A 37-year-old male with potential Kernohan’s Notch phenomenon (KNP) presenting with ipsilateral hemiplegia, dysphagia, and visual deficits following a parafalcine subdural hemorrhage (SDH) and traumatic brain injury (TBI).

Case Description or Program Description: The patient was a code 1 trauma after a high-speed motor vehicle collision, arriving with a Glasgow Coma Scale score of 3 and experiencing cardiac arrest en route (ROSC achieved). Imaging showed a 1.4 cm right parafalcine SDH with 1.4 cm right-to-left subfalcine shift, early transtentorial herniation, and trace right cortical subarachnoid hemorrhage. Emergent right craniectomy and SDH evacuation were performed, along with left frontal ventriculostomy.

Setting: Inpatient rehabilitation unit at a post-acute and tertiary care hospital.

Assessment/Results: Upon admission to the inpatient rehabilitation unit, the patient presented with right-sided hemiplegia, cognitive deficits, dysphagia requiring a PEG tube, right-sided neglect, and right visual field deficits. The patient’s initial FIM score was 42, indicating significant dependence. A multidisciplinary team implemented a rehabilitation plan that included: Physical therapy focused on gait training and strengthening, progressing from wheelchair-bound to walking 150 feet with a quad cane; Occupational therapy targeted ADLs and fine motor skills, with improvements in upper extremity function; Speech therapy managed dysphagia, transitioning the patient from PEG tube feeding to full oral intake; Cognitive therapy enhanced attention and memory, improving overall cognitive function.

Discussion (relevance): This case underscores the importance of recognizing KNP in patients with SDH and ipsilateral motor deficits, as delayed diagnosis can hinder targeted rehabilitation efforts. The co-occurrence of dysphagia and visual field deficits highlights the complex, multifocal impairments stemming from transtentorial herniation and brainstem involvement.

Conclusions: Early identification of KNP facilitated a tailored rehabilitation plan addressing motor re-education, dysphagia management, and cognitive recovery. This case adds to the limited rehabilitation-focused literature on KNP and emphasizes the need for heightened clinical suspicion when ipsilateral motor deficits accompany brain injury.