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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 1  |  Page : 79-80

Paradoxical herniation caused by cerebrospinal fluid drainage after decompressive craniectomy


1 Department of Surgery, West China Hospital, Sichuan University, Chengdu 610041; Department of Surgery, Dujiangyan People's Hospital, Dujiangyan Medical Center, Dujiangyan 611830, China
2 Department of Surgery, Dujiangyan People's Hospital, Dujiangyan Medical Center, Dujiangyan 611830, China
3 Department of Surgery, West China Hospital, Sichuan University, Chengdu 610041, China

Date of Submission08-Dec-2013
Date of Decision26-Dec-2013
Date of Acceptance26-Jan-2014
Date of Web Publication7-Mar-2014

Correspondence Address:
Qiang-ping Wang
Department of Surgery, West China Hospital, Sichuan University, Chengdu 610041; Department of Surgery, Dujiangyan People's Hospital, Dujiangyan Medical Center, Dujiangyan 611830
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.128337

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How to cite this article:
Wang Qp, Zhou Zm, You C. Paradoxical herniation caused by cerebrospinal fluid drainage after decompressive craniectomy. Neurol India 2014;62:79-80

How to cite this URL:
Wang Qp, Zhou Zm, You C. Paradoxical herniation caused by cerebrospinal fluid drainage after decompressive craniectomy. Neurol India [serial online] 2014 [cited 2019 Nov 18];62:79-80. Available from: http://www.neurologyindia.com/text.asp?2014/62/1/79/128337


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.
Figure 1: Axial non-contrast computed tomography scan images obtained after decompressive hemicraniectomy for the acute right hemispheric infarct

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Figure 2: Axial computed tomography scan showing midline shift with transtentorial herniation in the direction opposite the site of craniectomy

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Figure 3: Repeat brain computed tomography scan after clamping of the cerebrospinal fl uid drainage, positioning of the patient in Trendelenberg and hypervolemic therapy showing resolution of the midline shift and transtentorial herniation

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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 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.
Table 1: Main patients reported as having paradoxical herniation caused by CSF drainage or lumbar puncture after
decompressive craniectomy


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 ╗ References Top

1.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.  Back to cited text no. 1
    
2.Jung HJ, Kim DM, Kim SW. Paradoxical transtentorial herniation caused by lumbar puncture after decompressive craniectomy. J Korean Neurosurg Soc 2012;51:102-4.  Back to cited text no. 2
    
3.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.  Back to cited text no. 3
    
4.Schwab S, Erbguth F, Aschoff A, Orberk E, Spranger M, Hacke W. "Paradoxical" herniation after decompressive trephining. Nervenarzt 1998;69:896-900.  Back to cited text no. 4
    
5.Vilela MD. Delayed paradoxical herniation after a decompressive craniectomy: Case report. Surg Neurol 2008;69:293-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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