Paradoxical Herniation in the Postcraniectomy Syndrome: Report and Literature Update

Paradoxical Brain Herniation: An Unexpected Diagnosis

Paradoxical herniation is a dreadful neurosurgical complication often underdiagnosed, which typically becomes evident over the course of weeks to months after the initial intervention. Here we present a unique case with manifestations in the post-operative period. A patient initially referred to neurosurgery for a meningioma underwent an uneventful surgical excision, followed by the transient placement of a lumbar drain for 48 hours. On the first post-operative day, the patient exhibited progressively altered neurological status, with corresponding imaging revealing a transfalcine herniation, necessitating emergent decompressive craniectomy. Despite the medical and surgical interventions, there were continuous signs of neurological and imaging worsening, with increase in herniation, which led to the diagnosis suspicion of a paradoxical brain herniation. Consequently, a rapid reversal of neurological deficits was observed after applying maneuvers to augment the intracranial pressure, followed by cranioplasty. This case illustrates the utmost importance of clinical suspicion for the uncommon complications of neurointerventions.

Acute paradoxical brain herniation after decompressive craniectomy for severe traumatic brain injury: A case report

Background:

Sinking skin flap syndrome or paradoxical brain herniation is an uncommon neurosurgical complication, which usually occurs in the chronic phase after decompressive craniectomy. We report a unique case presenting with these complications immediately after decompressive craniectomy for severe traumatic brain injury.

Case Description:

A 65-year-old man had a right acute subdural hematoma (SDH), contusion of the right temporal lobe, and diffuse traumatic subarachnoid hemorrhage with midline shift to the left side. He underwent an emergency evacuation of the right SDH with a right decompressive frontotemporal craniectomy. Immediately after the operation, his neurological and computed tomography (CT) findings had improved. However, within 1 h after the surgery, his neurological signs deteriorated. An additional follow-up CT showed a marked midline shift to the left, i.e., paradoxical brain herniation, and his skin flap overlying the decompressive site was markedly sunken. We immediately performed an urgent cranioplasty with the right temporal lobectomy. He responded well to the procedure. We suspected that a cerebrospinal fluid leak had caused this phenomenon.

Conclusion:

Decompressive craniectomy for severe traumatic brain injury can lead to sinking skin flap syndrome and/or paradoxical brain herniation even in the acute phase. We believe that immediate cranioplasty allows the reversal of such neurosurgical complications.

Sinking Skin Flap Syndrome After Decompressive Craniectomy: A Case Report

Sinking skin flap syndrome is a rare complication of decompressive craniectomy characterized by a sunken skin flap, neurological deterioration, and paradoxical herniation of the brain. An absent cranium allows for external compression via atmospheric pressure, causing alterations in cerebral blood flow, cerebral spinal fluid flow, and glucose metabolism, which ultimately leads to cortical dysfunction. This case report describes a patient with relatively early onset of variable neurological symptoms and imaging correlation, leading to a diagnosis and definitive therapeutic intervention with cranioplasty. Prompt recognition is critical to avoid potentially devastating neurological outcomes in this rare, but underreported condition.

Neurosurgical complications: what the radiologist needs to know

Visits to the emergency department by patients who have recently undergone neurosurgery are a common occurrence, and these patients frequently receive emergent cross-sectional head imaging in order to evaluate for complications. Different neurosurgical approaches may have typical postoperative imaging findings that can be confused with pathology. Furthermore, particular abnormal postoperative imaging findings may signal an evolving complication. It is essential for the radiologist to understand common neurosurgical procedures and their potential complications in order to provide proper diagnostic evaluation of the postoperative neurosurgical patient. The purpose of this review is to assist radiologists in the evaluation of the postoperative neurosurgical patient and educate them on associated complications. Familiarity with common neurosurgical techniques and postoperative complications will help radiologists make the correct diagnosis, communicate effectively with the neurosurgeon, and expedite patient care.