A 72-year-old woman was brought to the emergency department in cardiac arrest. Return of spontaneous circulation was reestablished. She was subsequently comatose with absent brainstem reflexes. In the setting of diffuse hypoxic injury, MRI revealed diffuse cerebral edema and absent cerebral perfusion, suggesting brain death. Due to substantially increased intracranial pressure, there was downward central intrasellar herniation of the gyri recti, posterior orbital gyri, septal area, anterior third ventricle, anterior hypothalamus, and optic chiasm (figures 1 and 2). Several types of acquired herniation are well known and extensively discussed in the literature.1,2 Intrasellar downward cerebral herniation has not previously been described.