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Paradoxical herniation caused by cerebrospinal fluid drainage after decompressive craniectomy Sir, Paradoxical herniation is a rare complication mainly caused by cerebrospinal fluid (CSF) drainage and lumbar puncture in the presence of decompressive craniectomy. We present a case of paradoxical herniation secondary to CSF drainage after decompressive craniectomy for a large right hemispheric infarction. A 43-year-old male with a right-sided hypertensive basal ganglia hemorrhage underwent a hematoma evacuation. On post-operative day-3, patient was still unarousable. Computed tomography (CT) brain scan showed severe brain swelling caused by cerebral infarction and right frontotemporoparietal decompressive hemicraniectomy was performed [Figure 1]. The patient was sustainedly unconscious post-operatively. Subsequently, a lumbar puncture was done to rule out meningitis as the patient had a high-grade fever. CSF analysis showed high protein and continuous CSF drainage was placed to control the infection. There was right pupil dilatation 2 h post-operatively. Head CT showed marked herniation to the left [Figure 2]. With a possible diagnosis of paradoxical herniation, CSF drainage was immediately discontinued. He was placed in the Trendelenburg position and was appropriately hydrated. Within 3 h, his condition improved. His skull flap was no longer concave and the pupillary abnormalities resolved. Follow-up brain CT scan confirmed resolution of the herniation [Figure 3]. Unfortunately, the patient died from respiratory failure caused by severe pulmonary infection 26 days later. Decompressive craniectomy has been done more frequently in the past decades due to its beneficial effect benefits in traumatic brain injury with medically refractory intracranial pressures, subdural hematoma, space occupying cerebral edema and other clinical settings.[1] After the decompressive craniectomy, the intracranial contents are exposed to atmospheric pressure. Intracranial pressure opposes the atmospheric pressure, preventing herniation of the brain in normal condition. When the intracranial pressure is lowered by therapeutic procedures such as CSF drainage and lumbar puncture will result in negative gradient between atmospheric and intracranial pressure. The negative gradient, exacerbated by an upright posture, CSF leakage or dehydration, shifts the brain parenchyma away from the site of the
Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
Figure 1: Axial non-contrast computed tomography scan images obtained after decompressive hemicraniectomy for the acute right hemispheric infarct
Figure 2: Axial computed tomography scan showing midline shift with transtentorial herniation in the direction opposite the site of craniectomy
Figure 3: Repeat brain computed tomography scan after clamping of the cerebrospinal fluid drainage, positioning of the patient in Trendelenberg and hypervolemic therapy showing resolution of the midline shift and transtentorial herniation
79
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Table 1: Main patients reported as having paradoxical herniation caused by CSF drainage or lumbar puncture after decompressive craniectomy
Author, year Schwab et al., 1998 Oyelese et al., 2005 Fields et al., 2006
No. of Primary disease patients 4 1
Encephalitis, subdural hematoma, stroke Suprasellar meningioma
1
Traumatic subdural hemorrhage
Vilela, 2008
1
Jung et al., 2012
1
The presented case
1
Subarachnoid hemorrhage Traumatic epidural hematoma Hypertensive basal ganglia hemorrhage
Cause
Treatment
Prognosis
Lumbar puncture
Positioning the patient head down, administering IV fluids and doing an early cranioplasty Lumbar puncture The patient died from arrhythmia before any specific treatment could be instituted Ventriculoperitoneal Tying off the ventriculoperitoneal shunt, positioning the shunt patient in the Trendelenberg position and administering IV fluids Lumbar puncture Trendelenberg position and doing an emergent cranioplasty Lumbar puncture Trendelenberg position and administering sufficient hydration CSF drainage Tying off the CSF drainage, Trendelenberg position, administering sufficient hydration
Survival Death Survival
Survival Survival Death
IV - Intravenous, CSF - Cerebrospinal fluid
craniectomy, resulting in transtentorial herniation. Because its mechanism is different from the common herniation syndromes, this situation has been described as “paradoxical herniation” due to its specific mechanism.[2] As the paradoxical herniation represents low intracranial pressure state relative to extra-cranial pressure, traditional treatments for herniation syndromes such as mannitol, CSF drainage and hyperventilation will exacerbate the disorder and may even result in death,[3] because lowering intracranial pressure will increase the pressure gradient across the craniectomy defect. There had been a few case reports of paradoxical herniation caused by CSF drainage or lumbar puncture after decompressive craniectomy [Table 1]. The common and effective maneuvers are: Clamping of CSF drainage, Trendelenberg position and hydration. Early or even emergent cranioplasty may be of great value for patients’ recovery.[1,2,4,5] Although most cases reported good outcomes with these procedures. There were two deaths related to compilations, one reported by Oyelese et al.[3] and the present patient. We advise that neurosurgeons should recognize the presence of cranial defect as a relative contraindication to performing a lumbar puncture or CSF drainage. If necessary, care should be taken to perform the procedure with the patient in the head-down position to minimize the pressure gradient. Moreover, it is of vital importance to observe the patients during the performance and treat the situation properly.
Qiang-ping Wang1,2, Zhang-ming Zhou2, Chao You1 Departments of Surgery, 1West China Hospital, Sichuan University, Chengdu 610041, 2Dujiangyan People’s Hospital, Dujiangyan Medical Center, Dujiangyan 611830, China E-mail: kouxiangtang7595@163 80
References 1. 2. 3.
4. 5.
Fields JD, Lansberg MG, Skirboll SL, Kurien PA, Wijman CA. “Paradoxical” transtentorial herniation due to CSF drainage in the presence of a hemicraniectomy. Neurology 2006;67:1513-4. Jung HJ, Kim DM, Kim SW. Paradoxical transtentorial herniation caused by lumbar puncture after decompressive craniectomy. J Korean Neurosurg Soc 2012;51:102-4. Oyelese AA, Steinberg GK, Huhn SL, Wijman CA. Paradoxical cerebral herniation secondary to lumbar puncture after decompressive craniectomy for a large space-occupying hemispheric stroke: Case report. Neurosurgery 2005;57:E594. Schwab S, Erbguth F, Aschoff A, Orberk E, Spranger M, Hacke W. “Paradoxical” herniation after decompressive trephining. Nervenarzt 1998;69:896-900. Vilela MD. Delayed paradoxical herniation after a decompressive craniectomy: Case report. Surg Neurol 2008;69:293-6. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128337
Received: 08-12-2013 Review completed: 26-12-2013 Accepted: 26-01-2014
Large unruptured proximal (A1) anterior cerebral artery aneurysm with aplasia of the contralateral A1 Sir, Aneurysms from proximal A1 horizontal segment of anterior cerebral artery (ACA) are rare and may Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Paradoxical herniation caused by cerebrospinal fluid drainage after decompressive craniectomy Sir, Paradoxical herniation is a rare complication mainly caused by cerebrospinal fluid (CSF) drainage and lumbar puncture in the presence of decompressive craniectomy. We present a case of paradoxical herniation secondary to CSF drainage after decompressive craniectomy for a large right hemispheric infarction. A 43-year-old male with a right-sided hypertensive basal ganglia hemorrhage underwent a hematoma evacuation. On post-operative day-3, patient was still unarousable. Computed tomography (CT) brain scan showed severe brain swelling caused by cerebral infarction and right frontotemporoparietal decompressive hemicraniectomy was performed [Figure 1]. The patient was sustainedly unconscious post-operatively. Subsequently, a lumbar puncture was done to rule out meningitis as the patient had a high-grade fever. CSF analysis showed high protein and continuous CSF drainage was placed to control the infection. There was right pupil dilatation 2 h post-operatively. Head CT showed marked herniation to the left [Figure 2]. With a possible diagnosis of paradoxical herniation, CSF drainage was immediately discontinued. He was placed in the Trendelenburg position and was appropriately hydrated. Within 3 h, his condition improved. His skull flap was no longer concave and the pupillary abnormalities resolved. Follow-up brain CT scan confirmed resolution of the herniation [Figure 3]. Unfortunately, the patient died from respiratory failure caused by severe pulmonary infection 26 days later. Decompressive craniectomy has been done more frequently in the past decades due to its beneficial effect benefits in traumatic brain injury with medically refractory intracranial pressures, subdural hematoma, space occupying cerebral edema and other clinical settings.[1] After the decompressive craniectomy, the intracranial contents are exposed to atmospheric pressure. Intracranial pressure opposes the atmospheric pressure, preventing herniation of the brain in normal condition. When the intracranial pressure is lowered by therapeutic procedures such as CSF drainage and lumbar puncture will result in negative gradient between atmospheric and intracranial pressure. The negative gradient, exacerbated by an upright posture, CSF leakage or dehydration, shifts the brain parenchyma away from the site of the
Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
Figure 1: Axial non-contrast computed tomography scan images obtained after decompressive hemicraniectomy for the acute right hemispheric infarct
Figure 2: Axial computed tomography scan showing midline shift with transtentorial herniation in the direction opposite the site of craniectomy
Figure 3: Repeat brain computed tomography scan after clamping of the cerebrospinal fluid drainage, positioning of the patient in Trendelenberg and hypervolemic therapy showing resolution of the midline shift and transtentorial herniation
79
[Downloaded free from http://www.neurologyindia.com on Thursday, March 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for thi journal Letters to Editor
Table 1: Main patients reported as having paradoxical herniation caused by CSF drainage or lumbar puncture after decompressive craniectomy
Author, year Schwab et al., 1998 Oyelese et al., 2005 Fields et al., 2006
No. of Primary disease patients 4 1
Encephalitis, subdural hematoma, stroke Suprasellar meningioma
1
Traumatic subdural hemorrhage
Vilela, 2008
1
Jung et al., 2012
1
The presented case
1
Subarachnoid hemorrhage Traumatic epidural hematoma Hypertensive basal ganglia hemorrhage
Cause
Treatment
Prognosis
Lumbar puncture
Positioning the patient head down, administering IV fluids and doing an early cranioplasty Lumbar puncture The patient died from arrhythmia before any specific treatment could be instituted Ventriculoperitoneal Tying off the ventriculoperitoneal shunt, positioning the shunt patient in the Trendelenberg position and administering IV fluids Lumbar puncture Trendelenberg position and doing an emergent cranioplasty Lumbar puncture Trendelenberg position and administering sufficient hydration CSF drainage Tying off the CSF drainage, Trendelenberg position, administering sufficient hydration
Survival Death Survival
Survival Survival Death
IV - Intravenous, CSF - Cerebrospinal fluid
craniectomy, resulting in transtentorial herniation. Because its mechanism is different from the common herniation syndromes, this situation has been described as “paradoxical herniation” due to its specific mechanism.[2] As the paradoxical herniation represents low intracranial pressure state relative to extra-cranial pressure, traditional treatments for herniation syndromes such as mannitol, CSF drainage and hyperventilation will exacerbate the disorder and may even result in death,[3] because lowering intracranial pressure will increase the pressure gradient across the craniectomy defect. There had been a few case reports of paradoxical herniation caused by CSF drainage or lumbar puncture after decompressive craniectomy [Table 1]. The common and effective maneuvers are: Clamping of CSF drainage, Trendelenberg position and hydration. Early or even emergent cranioplasty may be of great value for patients’ recovery.[1,2,4,5] Although most cases reported good outcomes with these procedures. There were two deaths related to compilations, one reported by Oyelese et al.[3] and the present patient. We advise that neurosurgeons should recognize the presence of cranial defect as a relative contraindication to performing a lumbar puncture or CSF drainage. If necessary, care should be taken to perform the procedure with the patient in the head-down position to minimize the pressure gradient. Moreover, it is of vital importance to observe the patients during the performance and treat the situation properly.
Qiang-ping Wang1,2, Zhang-ming Zhou2, Chao You1 Departments of Surgery, 1West China Hospital, Sichuan University, Chengdu 610041, 2Dujiangyan People’s Hospital, Dujiangyan Medical Center, Dujiangyan 611830, China E-mail: kouxiangtang7595@163 80
References 1. 2. 3.
4. 5.
Fields JD, Lansberg MG, Skirboll SL, Kurien PA, Wijman CA. “Paradoxical” transtentorial herniation due to CSF drainage in the presence of a hemicraniectomy. Neurology 2006;67:1513-4. Jung HJ, Kim DM, Kim SW. Paradoxical transtentorial herniation caused by lumbar puncture after decompressive craniectomy. J Korean Neurosurg Soc 2012;51:102-4. Oyelese AA, Steinberg GK, Huhn SL, Wijman CA. Paradoxical cerebral herniation secondary to lumbar puncture after decompressive craniectomy for a large space-occupying hemispheric stroke: Case report. Neurosurgery 2005;57:E594. Schwab S, Erbguth F, Aschoff A, Orberk E, Spranger M, Hacke W. “Paradoxical” herniation after decompressive trephining. Nervenarzt 1998;69:896-900. Vilela MD. Delayed paradoxical herniation after a decompressive craniectomy: Case report. Surg Neurol 2008;69:293-6. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128337
Received: 08-12-2013 Review completed: 26-12-2013 Accepted: 26-01-2014
Large unruptured proximal (A1) anterior cerebral artery aneurysm with aplasia of the contralateral A1 Sir, Aneurysms from proximal A1 horizontal segment of anterior cerebral artery (ACA) are rare and may Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
