Brain stem herniation secondary to cerebrospinal fluid drainage in ruptured aneurysm surgery: a case report

Abstract

BackgroundA lumbar drainage catheter is frequently placed intra-operatively to decrease fluid pressure on the brain in aneurysmal subarachnoid cases. In rare cases, this catheter placement can lead to intracranial hypotension, resulting in brain stem herniation termed “brain sag” and it can lead to neurological injury and may prove to be fatal. We present our patient with brain sag secondary to intraoperative lumbar drainage. Case descriptionA 56-year-old woman was admitted with a sudden onset of severe headache. A computed tomography (CT) scan revealed diffuse subarachnoid hemorrhage with ruptured anterior communicating artery aneurysm. After general anesthesia, a lumbar drainage catheter was placed intra-operatively to reduce pressure on the brain and 50 cc of CSF was removed during a 5-h period. Three to five days after operation, her neurologic symptoms became worse with an altered mental state and pupillary asymmetry. CT and magnetic resonance imaging (MRI) showed slit lateral ventricles, effacement of the cisterns and an elongated brain stem. After placing the patient in the Trendelenburg position, the patient rapidly recovered to her baseline neurologic state. DiscussionTypical complications of subarachnoid hemorrhage such as vasospasm or hydrocephalus also manifest as neurological deterioration, but their treatments differ greatly from those for brain sag. Thusly, it is important to distinguish between causes. Treatments such as lumbar or extra-ventricular drainage, induced hypertension or administration of mannitol must be stopped once brain sag is suspected. Also, care should be taken for typical imaging features of brain sag on CT or MRI scan. For brain sag, placing the patient in the Trendelenburg position can improve neurological status in a rapid fashion.ConclusionsBrain sag is a rare but serious condition and can be fatal if not rapidly diagnosed and treated. We therefore recommend including brain sag in the differential diagnosis, along with vasospasm, hydrocephalus or cerebral edema as part of possible complications following subarachnoid hemorrhage treatment. We hope our clinical and imaging data from this case study contribute to the correct diagnosis of brain sag, as its early detection is important.

Intraoperative lumbar drainage can prevent cerebrospinal fluid leakage during transsphenoidal surgery for pituitary adenomas: a systematic review and meta-analysis

“…(5) LD can reduce CSF leakage, but LD complication rates were reported as 3% for major and 5% for minor complications [ 24 ]. Complications included headache, nausea, and vomiting [ 25 , 26 ]; meningitis and other infections [ 27 , 28 ]; abducens palsy [ 29 ]; intracranial hypotension [ 30 ]; cerebellar tonsillar herniation [ 31 ]; intracranial venous thrombosis [ 32 ]; and lumbar nerve root irritation, retained catheters and pneumocephalus [ 20 ]. These complications can lead to higher costs, longer hospital stays, and most importantly, more suffering.…”

Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial

“…21 Continuation of LD for more than several days postoperatively is risky because a longer duration of LD is correlated with higher rates of infection. 36 Other rare but serious complications include neurological deficits due to excessive drainage with tonsillar herniation, acute or delayed intracranial hypotension, 20,35 intracranial venous thrombosis, 26 lumbar nerve root irritation, pneumocephalus, and retained catheters. These are all in addition to the systemic complications associated with the relative immobilization of the patient required for safe LD usage.…”

Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair

“…13 Another rare but fatal complication of CSFD is brain herniation as a result of intracranial hypotension due to excessive CSF drainage leading to brain sag and brain stem herniation. 14 We did not encounter this complication in any of our patients.…”