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Yamada SM, Iwamoto N, Tomita Y, Takeda R, Nakane M. Midline Shift Induced by the Drainage of Cerebrospinal Fluid in Three Patients With External Decompression. Cureus 2023; 15:e44355. [PMID: 37779764 PMCID: PMC10539714 DOI: 10.7759/cureus.44355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
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.
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Affiliation(s)
- Shoko M Yamada
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Naotaka Iwamoto
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Yusuke Tomita
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Ririko Takeda
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Makoto Nakane
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
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2
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Yen L, Lin P. Middle‐aged man with conscious disturbance and left hemiparesis. J Am Coll Emerg Physicians Open 2022; 3:e12671. [PMID: 35224548 PMCID: PMC8857554 DOI: 10.1002/emp2.12671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/03/2022] [Accepted: 01/11/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Li‐Cheng Yen
- Department of Emergency Medicine Taipei Veterans General Hospital Taipei Taiwan
| | - Pei‐Ying Lin
- Department of Emergency Medicine Taipei Veterans General Hospital Taipei Taiwan
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3
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Mraček J, Mork J, Dostal J, Tupy R, Mrackova J, Priban V. Complications Following Decompressive Craniectomy. J Neurol Surg A Cent Eur Neurosurg 2021; 82:437-445. [PMID: 33618416 DOI: 10.1055/s-0040-1721001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications. METHODS We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed. RESULTS DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome. CONCLUSIONS The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.
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Affiliation(s)
- Jan Mraček
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Jan Mork
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Jiri Dostal
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Radek Tupy
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Jolana Mrackova
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Vladimir Priban
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
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4
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Hiruta R, Jinguji S, Sato T, Murakami Y, Bakhit M, Kuromi Y, Oda K, Fujii M, Sakuma J, Saito K. Acute paradoxical brain herniation after decompressive craniectomy for severe traumatic brain injury: A case report. Surg Neurol Int 2019; 10:79. [PMID: 31528417 PMCID: PMC6744802 DOI: 10.25259/sni-235-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 04/04/2019] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Ryo Hiruta
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Shinya Jinguji
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Taku Sato
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Yuta Murakami
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Mudathir Bakhit
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Yosuke Kuromi
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Keiko Oda
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Jun Sakuma
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
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5
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Gopalakrishnan MS, Shanbhag NC, Shukla DP, Konar SK, Bhat DI, Devi BI. Complications of Decompressive Craniectomy. Front Neurol 2018; 9:977. [PMID: 30524359 PMCID: PMC6256258 DOI: 10.3389/fneur.2018.00977] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/30/2018] [Indexed: 11/13/2022] Open
Abstract
Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.
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Affiliation(s)
- M S Gopalakrishnan
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Nagesh C Shanbhag
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Subhas K Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - B Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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6
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Early Occurrence of Sinking Skin Flap Syndrome in a State of Intracranial Hypertension. Clin Neuroradiol 2017; 28:297-300. [DOI: 10.1007/s00062-017-0635-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
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7
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Shen L, Qiu S, Su Z, Ma X, Yan R. Lumbar puncture as possible cause of sudden paradoxical herniation in patient with previous decompressive craniectomy: report of two cases. BMC Neurol 2017; 17:147. [PMID: 28768486 PMCID: PMC5541649 DOI: 10.1186/s12883-017-0931-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 07/28/2017] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Liang Shen
- Department of Neurosurgery, Huzhou Central Hospital, 198 Hongqi Road, Huzhou, Zhejiang, 313000, China
| | - Sheng Qiu
- Department of Neurosurgery, Huzhou Central Hospital, 198 Hongqi Road, Huzhou, Zhejiang, 313000, China
| | - Zhongzhou Su
- Department of Neurosurgery, Huzhou Central Hospital, 198 Hongqi Road, Huzhou, Zhejiang, 313000, China
| | - Xudong Ma
- Department of Neurosurgery, Huzhou Central Hospital, 198 Hongqi Road, Huzhou, Zhejiang, 313000, China
| | - Renfu Yan
- Department of Neurosurgery, Huzhou Central Hospital, 198 Hongqi Road, Huzhou, Zhejiang, 313000, China. .,School of Medicine, Huzhou University, 759 East Second Ring Road, Huzhou, Zhejiang, 313000, China.
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8
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Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2017; 29:191-210. [DOI: 10.1097/ana.0000000000000407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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9
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Paradoxical Herniation following Decompressive Craniectomy in the Subacute Setting. Case Rep Neurol Med 2016; 2016:2090384. [PMID: 27446619 PMCID: PMC4944054 DOI: 10.1155/2016/2090384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 06/12/2016] [Indexed: 11/17/2022] Open
Abstract
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.
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10
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Nasi D, Dobran M, Iacoangeli M, Di Somma L, Gladi M, Scerrati M. Paradoxical Brain Herniation After Decompressive Craniectomy Provoked by Drainage of Subdural Hygroma. World Neurosurg 2016; 91:673.e1-4. [PMID: 27108031 DOI: 10.1016/j.wneu.2016.04.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/10/2016] [Accepted: 04/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Paradoxical brain herniation (PBH) is a rare and potentially life-threatening complication of decompressive craniectomy (DC) and results from the combined effects of brain gravity, atmospheric pressure and intracranial hypotension causing herniation in the direction opposite to the site of the DC with subsequent brainstem compression. To date, the cases of PBH reported in literature are spontaneous or provoked by a lumbar puncture, a cerebrospinal fluid (CSF) shunt, or ventriculostomy. CASE DESCRIPTION We present an uncommon case of PBH provoked by percutaneous drainage of a huge subdural hygroma (SH) ipsilateral to the decompressive craniectomy causing mass effect and neurologic deterioration. After percutaneous evacuation of SH, the patient became unresponsive with dilated and fixed left pupil. A brain computed tomography scan showed marked midline shift in the direction opposite to the craniectomy site with subfalcine herniation and effacement of the peripontine cisterns. Paradoxical brain herniation (PBH) was diagnosed. Conservative treatment failed, and the patient required an emergency cranioplasty for reverse PBH. CONCLUSIONS The present case highlights the possibility that all forms of CSF depletion, including percutaneous drainage of subdural CSF collection and not only CSF shunting and/or lumbar puncture, can be dangerous for patients with large craniotomies and result in PBH. Moreover, an emergency cranioplasty could represent a safe and effective procedure in patients not responding to conservative treatment.
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Affiliation(s)
- Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy.
| | - Mauro Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia Di Somma
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Gladi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
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11
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Chen W, Guo J, Wu J, Peng G, Huang M, Cai C, Yang Y, Wang S. Paradoxical Herniation After Unilateral Decompressive Craniectomy Predicts Better Patient Survival: A Retrospective Analysis of 429 Cases. Medicine (Baltimore) 2016; 95:e2837. [PMID: 26945365 PMCID: PMC4782849 DOI: 10.1097/md.0000000000002837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 01/21/2016] [Accepted: 01/26/2016] [Indexed: 02/05/2023] Open
Abstract
Paradoxical herniation (PH) is a life-threatening emergency after decompressive craniectomy. In the current study, we examined patient survival in patients who developed PH after decompressive craniectomy versus those who did not. Risk factors for, and management of, PH were also analyzed. This retrospective analysis included 429 consecutive patients receiving decompressive craniectomy during a period from January 2007 to December 2012. Mortality rate and Glasgow Outcome Scale (GOS) were compared between those who developed PH (n = 13) versus those who did not (n = 416). A stepwise multivariate logistic regression analysis was carried out to examine the risk factors for PH. The overall mortality in the entire sample was 22.8%, with a median follow-up of 6 months. Oddly enough, all 13 patients who developed PH survived beyond 6 months. Glasgow Coma Scale did not differ between the 2 groups upon admission, but GOS was significantly higher in subjects who developed PH. Both the disease type and coma degree were comparable between the 13 PH patients and the remaining 416 patients. In all PH episodes, patients responded to emergency treatments that included intravenous hydration, cerebral spinal fluid drainage discontinuation, and Trendelenburg position. A regression analysis indicated the following independent risk factors for PH: external ventriculostomy, lumbar puncture, and continuous external lumbar drainage. The rate of PH is approximately 3% after decompressive craniectomy. The most intriguing findings of the current study were the 0% mortality in those who developed PH versus 23.6% mortality in those who did not develop PH and significant difference of GOS score at 6-month follow-up between the 2 groups, suggesting that PH after decompressive craniectomy should be managed aggressively. The risk factors for PH include external ventriculostomy, ventriculoperitoneal shunt, lumbar puncture, and continuous external lumbar drainage.
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Affiliation(s)
- Weiqiang Chen
- From the Department of Neurosurgery, Fuzhou General Hospital of Nanjing Command, PLA, Fuzhou (WC, SW); Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, Shantou (WC, JG, JW, GP, YY); Department of Neurosurgery, Jieyang People's Hospital, Jieyang (MH); and Department of Neurosurgery (CC), Shantou Central Hospital, Shantou, Guangdong, China
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12
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Vasung L, Hamard M, Soto MCA, Sommaruga S, Sveikata L, Leemann B, Vargas MI. Radiological signs of the syndrome of the trephined. Neuroradiology 2016; 58:557-568. [DOI: 10.1007/s00234-016-1651-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
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13
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Feng Y, Wang Y. Coexistent of paradoxical herniation and subdural hygroma: a case report. Chin Neurosurg J 2015. [DOI: 10.1186/s41016-015-0012-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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14
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Creutzfeldt CJ, Vilela MD, Longstreth WT. Paradoxical herniation after decompressive craniectomy provoked by lumbar puncture or ventriculoperitoneal shunting. J Neurosurg 2015; 123:1170-5. [PMID: 26067613 DOI: 10.3171/2014.11.jns141810] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Two patients who underwent decompressive craniectomy after head trauma deteriorated secondary to paradoxical herniation, one after lumbar puncture and the other after ventriculoperitoneal shunting. They motivated the authors to investigate further provoked paradoxical herniation. METHODS The authors reviewed the records of 205 patients who were treated at a single hospital with decompressive craniectomy for head trauma to identify those who had had lumbar puncture performed or a ventriculoperitoneal shunt placed after craniectomy but before cranioplasty. Among the patients who met these criteria, those with provoked paradoxical herniation were identified. The authors also sought to identify similar cases from the literature. Exact binomials were used to calculate 95% CIs. RESULTS None of 26 patients who underwent a lumbar puncture within 1 month of craniectomy deteriorated, whereas 2 of 10 who underwent a lumbar puncture 1 month afterward did so (20% [95% CI 2.4%-55.6%]). Similarly, after ventriculoperitoneal shunting, 3 of 10 patients deteriorated (30% [95% CI 6.7%-65.2%]). Timing of the procedure and the appearance of the skin flap were important factors in deterioration after lumbar puncture but not after ventriculoperitoneal shunting. A review of the literature identified 15 additional patients with paradoxical herniation provoked by lumbar puncture and 7 by ventriculoperitoneal shunting. CONCLUSIONS Lumbar puncture and ventriculoperitoneal shunting carry substantial risk when performed in a patient after decompressive craniectomy and before cranioplasty. When the condition that prompts decompression (such as brain swelling associated with stroke or trauma) requires time to resolve, risk is associated with lumbar puncture performed ≥ 1 month after decompressive craniectomy.
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Affiliation(s)
| | - Marcelo D Vilela
- Neurological Surgery, and.,Mater Dei Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - William T Longstreth
- Departments of 1 Neurology.,Epidemiology, University of Washington, Seattle, Washington; and
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15
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Sinking skin flap syndrome and paradoxical herniation secondary to lumbar drainage. Clin Neurol Neurosurg 2015; 133:6-10. [DOI: 10.1016/j.clineuro.2015.03.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/17/2015] [Accepted: 03/07/2015] [Indexed: 11/18/2022]
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16
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Wang QP, Ma JP, Zhou ZM, Yang M, You C. Hydrocephalus after decompressive craniectomy for malignant hemispheric cerebral infarction. Int J Neurosci 2015; 126:707-12. [DOI: 10.3109/00207454.2015.1055357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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17
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Narro-Donate JM, Huete-Allut A, Escribano-Mesa JA, Rodríguez-Martínez V, Contreras-Jiménez A, Masegosa-González J. [Paradoxical transtentorial herniation, extreme trephined syndrome sign: A case report]. Neurocirugia (Astur) 2014; 26:95-9. [PMID: 25455761 DOI: 10.1016/j.neucir.2014.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/08/2014] [Accepted: 09/22/2014] [Indexed: 11/18/2022]
Abstract
The current increasing use of decompressive craniectomy carries the implicit appearance of complications due to alterations in both intracranial pressure and in the hydrostatic-hemodynamic equilibrium. Paradoxical transtentorial herniation represents a rare manifestation, included in "trephine syndrome", extremely critical but with relatively simple treatment. We present the case of a 56-year-old woman with no interesting medical history, who, after an olfactory groove meningioma surgery, presented a haemorrhage located in the surgical area with an important oedema. The patient required a second emergency surgery without any chance of conserving the cranial vault. During the post-operational period, great neurological deterioration in orthostatic position was noticed, which resolved spontaneously in decubitus. This deficit was resolved with bone replacement afterwards. We discuss possible predisposing factors and aetiologies of this pathology.
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Affiliation(s)
| | - Antonio Huete-Allut
- Departamento de Neurocirugía, Complejo Hospitalario Torrecárdenas, Almería, España
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18
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Picard NA, Zanardi CA. Brain motion in patients with skull defects: B-mode ultrasound observations on respiration-induced movements. Acta Neurochir (Wien) 2013; 155:2149-57. [PMID: 24009045 DOI: 10.1007/s00701-013-1838-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Since ancient times, brain motion has captured the attention of human beings. However, there are no reports about morphological changes that occur below the cortex or skin flap when a patient, with an open skull breathes, coughs, or engages effort. Thus, the aim of this study was to characterize brain motion caused by breathing movements in adults with an open skull. METHODS Twenty-five craniectomized patients were studied using B-mode ultrasonography during early and late postoperative periods. Twelve patients were analysed during surgery. Brain movements induced by breathing activity were assessed in this prospective observational study. RESULTS Taking as a reference the cranial base, an increase in intrathoracic pressure was accompanied by a rise of the brain due to the expansion of the basal cisterns. Greater increases in intrathoracic pressure (resulting from the Valsalva manoeuvre and coughing) propelled the brain in a block from the foramen magnum towards the craniectomy, mainly in structures near the tentorial incisure. Prolonging the Valsalva manoeuvre also resulted in thickening of the cortical mantle attributable to vascular congestion. The magnitude of these movements was directly related to breathing effort. CONCLUSIONS The increase in intrathoracic pressure was immediately transmitted to the brain by the rise of cerebrospinal fluid, while brain swelling attributable to vascular congestion showed a brief delay. The Valsalva manoeuvre and coughing caused abrupt morphological changes in the tentorial hiatus neighbouring structures because of the distension of the basal cisterns. These movements could play a role in the pathophysiology of the syndrome of trephined.
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Milton K, Chang GY. Ex-vacuo interna phenomenon. Eur J Neurol 2012; 19:e112-3. [PMID: 22971231 DOI: 10.1111/j.1468-1331.2012.03811.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jung HJ, Kim DM, Kim SW. Paradoxical transtentorial herniation caused by lumbar puncture after decompressive craniectomy. J Korean Neurosurg Soc 2012; 51:102-4. [PMID: 22500203 PMCID: PMC3322205 DOI: 10.3340/jkns.2012.51.2.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 08/23/2011] [Accepted: 02/07/2012] [Indexed: 11/27/2022] Open
Abstract
Although decompressive craniectomy is an effective treatment for various situations of increased intracranial pressure, it may be accompanied by several complications. Paradoxical herniation is known as a rare complication of lumbar puncture in patients with decompressive craniectomy. A 38-year-old man underwent decompressive craniectomy for severe brain swelling. He remained neurologically stable for five weeks, but then showed mental deterioration right after a lumbar puncture which was performed to rule out meningitis. A brain computed tomographic scan revealed a marked midline shift. The patient responded to the Trendelenburg position and intravenous fluids, and he achieved full neurologic recovery after successive cranioplasty. The authors discuss the possible mechanism of this rare case with a review of the literature.
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Affiliation(s)
- Heyun Jin Jung
- Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, Korea
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Voss HU, Heier LA, Schiff ND. Multimodal imaging of recovery of functional networks associated with reversal of paradoxical herniation after cranioplasty. Clin Imaging 2011; 35:253-8. [PMID: 21724116 DOI: 10.1016/j.clinimag.2010.07.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 07/16/2010] [Indexed: 10/28/2022]
Abstract
Cranioplasty following decompressive craniectomy is reported to result in improved blood flow, cerebral metabolism, and concomitant neurological recovery. We used multimodal functional imaging technology to study a patient with marked neurological recovery after cranioplasty. Resting-state networks and auditory responses obtained with functional MRI and cerebral metabolism obtained with PET before and after cranioplasty revealed significant functional changes that were correlated with the subject's neurological recovery. Our results suggest a link between recovery of behavior, cerebral metabolism, and resting-state networks following cranioplasty.
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Affiliation(s)
- Henning U Voss
- Department of Radiology and Citigroup Biomedical Imaging Center, Weill Cornell Medical College, New York, NY 10021, USA.
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Vogel TW, Dlouhy BJ, Howard MA. Use of confirmatory imaging studies to illustrate adequate treatment of cerebrospinal fluid leak in spontaneous intracranial hypotension. J Neurosurg 2010; 113:955-60. [DOI: 10.3171/2010.5.jns091405] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is a syndrome with serious neurological sequelae. As demonstrated by the following report, recurrent episodes of SIH can be difficult to diagnose when associated with other neurosurgical procedures, such as craniectomies. In this paper, the authors demonstrate SIH presenting as a subdural hematoma with recurrence of CSF leaks. Spontaneous intracranial hypotension was further complicated by paradoxical herniation following a craniectomy. Treatment of SIH necessitated multiple epidural blood patches for CSF leaks at different spinal levels and at different times. The efficacy of each epidural blood patch was confirmed with radionuclide imaging. Confirmation of effective blood patch placement may be useful for identifying patients at risk for a failed epidural blood patch or for patients whose neurological examination results have not fully improved.
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Rahme R, Bojanowski MW. Overt Cerebrospinal Fluid Drainage Is Not a Sine Qua Non for Paradoxical Herniation After Decompressive Craniectomy. Neurosurgery 2010; 67:214-5; discussion 215. [DOI: 10.1227/01.neu.0000370015.94386.1f] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE
Paradoxical transtentorial herniation is a rare but well-documented complication of cerebrospinal fluid (CSF) drainage in patients with large decompressive craniectomies. However, brain sagging in the absence of CSF hypovolemia has not been previously reported.
CLINICAL PRESENTATION
A 30-year-old woman suffered massive intracerebral hemorrhage from a small residual left frontal arteriovenous malformation 1 year following endovascular embolization and stereotactic radiosurgery. The patient initially presented in coma with left mydriasis and decorticate posturing and underwent emergent decompressive craniectomy, evacuation of the hematoma, and insertion of an intracranial pressure (ICP) monitor. Postoperatively, despite a depressed skin flap and low ICP readings, she continued to deteriorate neurologically, and CT revealed increasing midline shift, transtentorial herniation, and brainstem compression.
INTERVENTION OR TECHNIQUE
Although there was no history of CSF drainage, the diagnosis of brain sag was suspected, because herniation seemed to occur in the setting of intracranial hypotension. The patient was placed in a 15° Trendelenburg position and improved dramatically within hours. A few days later, she was fully awake and had purposeful movements with her left side, although she had persistent aphasia and right hemiplegia.
CONCLUSION
Although rare, paradoxical herniation in the setting of a large craniectomy defect may occur in the absence of CSF drainage. This entity should be suspected whenever transtentorial herniation occurs in conjunction with direct or indirect signs of intracranial hypotension. Placing the patient in the Trendelenburg position should be attempted, because this simple maneuver may turn out to be life-saving.
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Affiliation(s)
- Ralph Rahme
- Division of Neurosurgery, Hôpital Notre-Dame du CHUM, University of Montreal, Montreal, Quebec, Canada
| | - Michel W. Bojanowski
- Division of Neurosurgery, Hôpital Notre-Dame du CHUM, University of Montreal, Montreal, Quebec, Canada
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Abstract
Imaging plays an essential role in the evaluation of patients after cranial surgery. It is important to be familiar with the normal anatomy of the cranium; the indications for different surgical techniques such as burr holes, craniotomy, craniectomy, and cranioplasty; their normal postoperative appearances; and complications such as tension pneumocephalus, infection, abscess, empyema, hemorrhage, hematoma, herniation, hygroma, and trephine syndrome. Postoperative infection and hemorrhage are common to all neurosurgical procedures, where-as other complications are peculiar to certain procedures (eg, drill "plunging" during burr hole creation and sinking skin flap after craniec-tomy). Recognizing life-threatening complications such as tension pneumocephalus and paradoxical herniation, which require urgent intervention, is important for a better clinical outcome. Computed tomography is fast, cost effective, and easily accessible for first-line imaging. Magnetic resonance imaging has higher sensitivity for detecting postoperative infection and ischemia, but diffusion-weighted imaging may be less reliable for detecting postoperative infections.
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Affiliation(s)
- Audrey G Sinclair
- Department of Radiology Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB20QQ, England
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Abstract
Decompressive craniectomy is widely used to treat intracranial hypertension following traumatic brain injury (TBI). Two randomized trials are currently underway to further evaluate the effectiveness of decompressive craniectomy for TBI. Complications of this procedure have major ramifications on the risk-benefit balance in decision-making during evaluation of potential surgical candidates. To further evaluate the complications of decompressive craniectomy, a review of the literature was performed following a detailed search of PubMed between 1980 and 2009. The author restricted her study to literature pertaining to decompressive craniectomy for patients with TBI. An understanding of the pathophysiological events that accompany removal of a large piece of skull bone provides a foundation for understanding many of the complications associated with decompressive craniectomy. The author determined that decompressive craniectomy is not a simple, straightforward operation without adverse effects. Rather, numerous complications may arise, and they do so in a sequential fashion at specific time points following surgical decompression. Expansion of contusions, new subdural and epidural hematomas contralateral to the decompressed hemisphere, and external cerebral herniation typify the early perioperative complications of decompressive craniectomy for TBI. Within the 1st week following decompression, CSF circulation derangements manifest commonly as subdural hygromas. Paradoxical herniation following lumbar puncture in the setting of a large skull defect is a rare, potentially fatal complication that can be prevented and treated if recognized early. During the later phases of recovery, patients may develop a new cognitive, neurological, or psychological deficit termed syndrome of the trephined. In the longer term, a persistent vegetative state is the most devastating of outcomes of decompressive craniectomy. The risk of complications following decompressive craniectomy is weighed against the life-threatening circumstances under which this surgery is performed. Ongoing trials will define whether this balance supports surgical decompression as a first-line treatment for TBI.
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Akins PT, Guppy KH. Sinking Skin Flaps, Paradoxical Herniation, and External Brain Tamponade: A Review of Decompressive Craniectomy Management. Neurocrit Care 2007; 9:269-76. [DOI: 10.1007/s12028-007-9033-z] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Overdrainage of Cerebrospinal Fluid During Central Venous Catheter Exchange in a Patient with an External Ventricular Drain. Anesth Analg 2007; 105:1519-20. [DOI: 10.1213/01.ane.0000286081.49295.f3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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