Paradoxical herniation after decompressive craniectomy provoked by lumbar puncture or ventriculoperitoneal shunting

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.

Paradoxical herniation associated with hyperbaric oxygen therapy after decompressive craniectomy: A case report

BACKGROUND

Whether hyperbaric oxygen therapy (HBOT) can cause paradoxical herniation is still unclear.

CASE SUMMARY

A 65-year-old patient who was comatose due to brain trauma underwent decompressive craniotomy and gradually regained consciousness after surgery. HBOT was administered 22 d after surgery due to speech impairment. Paradoxical herniation appeared on the second day after treatment, and the patient's condition worsened after receiving mannitol treatment at the rehabilitation hospital. After timely skull repair, the paradoxical herniation was resolved, and the patient regained consciousness and had a good recovery as observed at the follow-up visit.

CONCLUSION

Paradoxical herniation is rare and may be caused by HBOT. However, the underlying mechanism is unknown, and the understanding of this phenomenon is insufficient. The use of mannitol may worsen this condition. Timely skull repair can treat paradoxical herniation and prevent serious complications.

Exploring complications following cranioplasty after decompressive hemicraniectomy: A retrospective bicenter assessment of autologous, PMMA and CAD implants

Cranioplasty (CP) after decompressive hemicraniectomy (DHC) is a common neurosurgical procedure with a high complication rate. The best material for the repair of large cranial defects is unclear. The aim of this study was to evaluate different implant materials regarding surgery related complications after CP. Type of materials include the autologous bone flap (ABF), polymethylmethacrylate (PMMA), calcium phosphate reinforced with titanium mesh (CaP-Ti), polyetheretherketone (PEEK) and hydroxyapatite (HA). A retrospective, descriptive, observational bicenter study was performed, medical data of all patients who underwent CP after DHC between January 1st, 2016 and December 31st, 2022 were analyzed. Follow-up was until December 31st, 2023. 139 consecutive patients with a median age of 54 years who received either PMMA (56/139; 40.3%), PEEK (35/139; 25.2%), CaP-Ti (21/139; 15.1%), ABF (25/139; 18.0%) or HA (2/139; 1.4%) cranial implant after DHC were included in the study. Median time from DHC to CP was 117 days and median follow-up period was 43 months. Surgical site infection was the most frequent surgery-related complication (13.7%; 19/139). PEEK implants were mostly affected (28.6%; 10/35), followed by ABF (20%; 5/25), CaP-Ti implants (9.5%; 2/21) and PMMA implants (1.7%, 1/56). Explantation was necessary for 9 PEEK implants (25.7%; 9/35), 6 ABFs (24.0%; 6/25), 3 CaP-Ti implants (14.3%; 3/21) and 4 PMMA implants (7.1%; 4/56). Besides infection, a postoperative hematoma was the most common cause. Median surgical time was 106 min, neither longer surgical time nor use of anticoagulation were significantly related to higher infection rates (p = 0.547; p = 0.152 respectively). Ventriculoperitoneal shunt implantation prior to CP was noted in 33.8% (47/139) and not significantly associated with surgical related complications. Perioperative lumbar drainage, due to bulging brain, inserted in 38 patients (27.3%; 38/139) before surgery was protective when it comes to explantation of the implant (p = 0.035). Based on our results, CP is still related to a relatively high number of infections and further complications. Implant material seems to have a high effect on postoperative infections, since surgical time, anticoagulation therapy and hydrocephalus did not show a statistically significant effect on postoperative complications in this study. PEEK implants and ABFs seem to possess higher risk of postoperative infection. More biocompatible implants such as CaP-Ti might be beneficial. Further, prospective studies are necessary to answer this question.

Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy

OBJECTIVE

Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC.

METHODS

The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema.

RESULTS

A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21).

CONCLUSIONS

In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.

Midline Shift Induced by the Drainage of Cerebrospinal Fluid in Three Patients With External Decompression

It is not rare that progressive hydrocephalus worsens clinical conditions in a patient with external decompression and drainage or shunt surgery is required. However, spinal drainage or shunt surgeries potentially carry a risk of causing paradoxical herniation in a patient with decompressive craniectomy, particularly in a comatose case with wide craniectomy. Careful and strict observations are necessary for such patients. In our three comatose cases with craniectomy, paradoxical herniation occurred due to excessive drainage after 5-7 days of shunt surgery and lumbar drainage, although the drainage pressure was set at more than 10 cmH2O. Fortunately, in the three cases, the herniation improved within a few days after the drain was clamped and the bed was flattened. However, the Trendelenburg position and epidural blood patch might be necessary if paradoxical herniation occurs acutely after lumbar puncture or drainage because delayed resolution can be fatal in the herniation.

Contralateral subdural effusion after decompressive craniectomy: What is the optimal treatment?

OBJECTIVE

Contralateral subdural effusion after decompressive craniectomy (CSEDC) is rare, and the optimal treatment is not determined. We present 11 cases of CSEDC and give an overview of the English literature pertaining to this disease.

METHODS

We searched the database at our institution and performed a search of English literature in PubMed and Google Scholar. Keywords used were as follows (single word or combination): "subdural hygroma"; "subdural effusion"; "decompressive craniectomy". Only patients with CSEDC and contained adequate clinical information pertinent to the analysis were included.

RESULTS

11 cases of CSEDC were recorded at our institution. They comprised ten men and one woman with an average age of 41.9 years. All the 8 symptomatic patients underwent surgery and the CSEDC resolved gradually. 68 cases of CSEDC were found in the literature. Including ours, a total of 79 patients were analyzed. Conservative treatment was effective in the asymptomatic patients. 41.7% of the symptomatic CSEDC underwent burr hole drainage and successfully drained the CSEDC. However, 76% of them received subsequent surgery to manage the reaccumulation of CSEDC. 25% of the symptomatic patients underwent cranioplasty, while 13.3% of them received Ommaya drainage later because of CSEDC recurrence. 18.3% of the symptomatic patients underwent cranioplasty plus subduroperitoneal shunting, and all CSEDC resolved completely.

CONCLUSIONS

Burr hole drainage appears to be only a temporary measure. Early cranioplasty should be performed for patients with CSEDC. CSF shunting procedures may be required for patients in whom CSEDC have not been solved or hydrocephalus manifest after cranioplasty.

Acute Paradoxical Herniation: A Case Report

Decompressive craniectomy is used to relieve acute increased intracranial pressure (ICP) when medical therapy has failed. Paradoxical herniation is a rare complication that occurs when the pressure of the intracranial contents falls abnormally below the atmospheric pressure. Symptoms often include neurological deficits, the etiology of which is often mistaken for elevated ICP. This diagnosis requires quick recognition, and treatment requires a change from ICP reduction therapies to those that increase the ICP, and ultimately cranioplasty.

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.

Head of the Bed Down: Paradoxical Management for Paradoxical Herniation

Emergency physicians are well versed in cerebral herniation, pathology that typically results from increased intracranial pressure; however, paradoxical herniation is less common and requires opposing treatments. We describe a case of paradoxical herniation following lumbar puncture in a patient with previous hemicraniectomy. The symptomatology was similar to cerebral herniation from intracranial hypertension and included lethargy, bradycardia, headache, and compression of brain structures on non-contrast head computed tomography. However, contrary to treatment modalities for intracranial hypertension, our management strategy aimed to reverse intracerebral hypotension. Treatment for paradoxical herniation involved increasing intracranial pressure using fluid resuscitation and Trendelenburg positioning. In the intensive care unit our patient received an epidural blood patch and hydration with resolution of his symptoms.

Risk of brain herniation after craniotomy with lumbar spinal drainage: a propensity score analysis

OBJECTIVE

Lumbar spinal drainage (LSD) during neurosurgery can have an important effect by facilitating a smooth procedure when needed. However, LSD is quite invasive, and the pathology of brain herniation associated with LSD has become known recently. The objective of this study was to determine the risk of postoperative brain herniation after craniotomy with LSD in neurosurgery overall.

METHODS

Included were 239 patients who underwent craniotomy with LSD for various types of neurological diseases between January 2007 and December 2016. The authors performed propensity score matching to establish a proper control group taken from among 1424 patients who underwent craniotomy and met the inclusion criteria during the same period. The incidences of postoperative brain herniation between the patients who underwent craniotomy with LSD (group A, n = 239) and the matched patients who underwent craniotomy without LSD (group B, n = 239) were compared.

RESULTS

Brain herniation was observed in 24 patients in group A and 8 patients in group B (OR 3.21, 95% CI 1.36-8.46, p = 0.005), but the rate of favorable outcomes was higher in group A (OR 1.79, 95% CI 1.18-2.76, p = 0.005). Of the 24 patients, 18 had uncal herniation, 5 had central herniation, and 1 had uncal and subfalcine herniation; 8 patients with other than subarachnoid hemorrhage were included. Significant differences in the rates of deep approach (OR 5.12, 95% CI 1.8-14.5, p = 0.002) and temporal craniotomy (OR 10.2, 95% CI 2.3-44.8, p = 0.002) were found between the 2 subgroups (those with and those without herniation) in group A. In 5 patients, brain herniation proceeded even after external decompression (ED). Cox regression analysis revealed that the risk of brain herniation related to LSD increased with ED (hazard ratio 3.326, 95% CI 1.491-7.422, p < 0.001). Among all 1424 patients, ED resulted in progression or deterioration of brain herniation more frequently in those who underwent LSD than it did in those who did not undergo LSD (OR 9.127, 95% CI 1.82-62.1, p = 0.004).

CONCLUSIONS

Brain herniation downward to the tentorial hiatus is more likely to occur after craniotomy with LSD than after craniotomy without LSD. Using a deep approach and craniotomy involving the temporal areas are risk factors for brain herniation related to LSD. Additional ED would aggravate brain herniation after LSD. The risk of brain herniation after placement of a lumbar spinal drain during neurosurgery must be considered even when LSD is essential.

Early post-operative cerebrospinal fluid hypovolemia: Report of 7 cases

Cerebrospinal fluid (CSF) hypovolemia is a common neurosurgical condition, which may be spontaneous or iatrogenic. At our institution, a substantial number of the reported cases of early post-operative CSF hypovolemia were identified to have unintentional or unrecognized post-operative continuous excessive CSF leakage. Cases who presented with post-operative CSF hypovolemia several days after uneventful intracranial surgeries without continuous CSF leakage were rarely reported. A retrospective review of the medical records of these patients was performed to identify those patients who developed early post-operative CSF hypovolemia without the presence of post-operative continuous CSF leakage. A total of 7 patients, 5 of which were males, were identified in this retrospective study. They experienced CSF hypovolemia between days 1 and 7 after emergency or scheduled intracranial surgeries. Ventricular collapse, cisternal effacement and midline shift are the most common radiological observations. With early diagnosis and management, 4 of the patients achieved a Glasgow Outcome Scale (GOS) score of 5, 1 achieved a GOS score of 4 and the remaining 2 had a GOS score of 3. No mortality was noted in this series. Although rare in incidence, early post-operative CSF hypovolemia may occur without the existence of post-operative continuous CSF leakage. When the diagnosis of CSF hypovolemia is reached, factors that may exacerbate CSF compensation should be promptly terminated. Trendelenburg position and sufficient intravenous hydration are practical and effective managements, and CSF hypovolemia may thereby be reversed in a substantial number of patients.

Refractory intracranial hypertension in traumatic brain injury: Proposal for a novel score to assess the safety of lumbar cerebrospinal fluid drainage

BACKGROUND

Cerebrospinal fluid (CSF) drainage via ventricular puncture is an established therapy of elevated intracranial pressure (ICP). In contrast, lumbar CSF removal is believed to be contraindicated with intracranial hypertension.

METHODS

We investigated the safety and efficacy of lumbar CSF drainage to decrease refractory elevated ICP in a small cohort of patients with traumatic brain injury (TBI). A score (0-8 points) was used to assess computed tomography (CT) images for signs of herniation and for patency of the basal cisterns. All patients received lumbar CSF drainage either as a continuous drainage or as a single lumbar puncture (LP). Type and method of CSF drainage, mean ICP 24 h prior and after CSF removal, and adverse events were documented. Outcome was assessed after 3 months (with dichotomized Glasgow outcome scale).

RESULTS

Eight patients were evaluated retrospectively. n = 5 suffered a moderate, n = 2 a severe TBI (one Glasgow coma score not documented). The CT score was ≥5 in all patients prior to LP and decreased after puncture without clinical consequences in two patients. The amount of CSF removal did not correlate with score changes (P = 0.45). CSF drainage led to a significant reduction of mean ICP (from 22.3 to 13.9 mmHg, P = 0.002). Continuous drainage was more effective than a single LP. Three of eight patients reached a favorable outcome.

CONCLUSIONS

Lumbar CSF removal for the treatment of intracranial hypertension is effective and safe, provided the basal cisterns are discernible, equivalent to ≥5 points in the proposed new score. The score needs further validation.

Lumbar puncture as possible cause of sudden paradoxical herniation in patient with previous decompressive craniectomy: report of two cases

Background

Lumbar puncture is often used for the diagnosis and treatment of subarchnoid hemorrhage, infection of Cerebro-spinal Fluid (CSF), hydrocephalus in neurosurgery department patients. It is general that paradoxical herniation followed by lumbar puncture is quite rare in decompressive craniectomy cases; the related reports are very few. Moreover, most of the paradoxical herniation cases are chronic, which often occur weeks or even months after the lumbar puncture, to date, barely no reports on the acute onset paradoxical herniation have been found.

Case presentation

Two traumatic brain injury patients with decompressive craniectomy (DC) and hydrocephalus suffered from a sudden paradoxical herniation after lumbar puncture. The symptoms of herniation were improved by treated with Trendelenburg position and rapid intravenous infusion.

Conclusions

Lumbar puncture may have a potential risk of inducing sudden paradoxical herniation in patients with DC. CSF drainage during lumbar puncture should be in small volume for patients with DC. Once a paradoxical herniation occurs after lumbar puncture, an immediate Trendelenburg position and rapid intravenous infusion treatment may be effective.

Intracerebral Hemorrhagic Infarction after Cranioplasty in a Patient with Sinking Skin Flap Syndrome

The sinking skin flap syndrome (SSFS) is a rare complication after a large craniectomy. Hemorrhage infarction after a cranioplasty is a very rare complication with only 4 cases to date. We report a case of the patient who underwent an autologous cranioplasty to treat SSFS that developed intracerebral hemorrhage infarction. A 20-year-old male was admitted to our emergency department with stuporous mentality. Emergent decompressive craniectomy (DC) have done. He had suffered from SSFS and fever of unknown origin (FUO) since DC. After 7 months of craniectomy, cranioplasty was done. After 1 day of surgery, acute infarction with hemorrhagic transformation involved left cerebral hemisphere. We controlled increased intracranial pressure by using osmotic diuretics, steroid and antiepileptic drugs. After 14 day of surgery, he improved neurological symptoms and he had not any more hyperthermia. Among several complication of large cranioplasty only 4 cases of intracerebral hemorrhagic infarction due to reperfusion injury has been reported. In this case, unstable autoregulation system made brain hypoxic damage and then reperfusion and recanalization of cerebral vessels resulted in intracerebral hemorrhagic infarction. 7 month long FUO was resolved by cranioplasty.

Paradoxical Herniation following Decompressive Craniectomy in the Subacute Setting

Decompressive craniectomy is reserved for extreme cases of intracranial hypertension. An uncommon complication known as paradoxical herniation has been documented within weeks to months following surgery. Here we present a unique case within days of surgery. Since standard medical treatment for intracranial hypertension will exacerbate paradoxical herniation, any abrupt neurological changes following decompressive craniectomy should be carefully investigated. Immediate treatment for paradoxical herniation is placement of the patient in the supine position with adequate hydration. Cranioplasty is the ultimate treatment option.