Paradoxical herniation caused by cerebrospinal fluid drainage after decompressive craniectomy

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

“…1) showed evidence of ventricular enlargement before lumbar puncture and thus lacked a sunken skin flap. In our series, 7 patients with a bulging skin flap tolerated a lumbar puncture without deterioration, but based on a recent case report, 20 such an appearance of the skin flap does not afford absolute protection.…”

“…2,[8][9][10][11]14,17,19,20 Cases of paradoxical herniation provoked by lumbar puncture are summarized in Table 1. Although the timing was not always easy to determine, lumbar puncture was typically performed > 1 month after the craniectomy, which had been performed for a variety of conditions, including encephalitis, abscess, tumor, ischemic stroke, and trauma.…”

Comment on: Paradoxical herniation caused by cerebrospinal fluid drainage after decompressive craniectomy

“…Sir, We read with interest the article "Paradoxical herniation caused by cerebrospinal fluid drainage after decompressive craniectomy" by Wang et al [1] and commend the authors on highlighting this uncommon complication after decompressive craniectomy (DC). Though the term "paradoxical herniation" was fi rst used by Schwab et al in 1998, [2] there is no clarity on what is "paradoxical" about this herniation and we feel the term is redundant.…”

Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

“…8 To limit potential for Clostridium difficile diarrhea and antimicrobial-resistant organisms, as well as lack of efficacy, antibiotics are not routinely recommended for the duration of the EVD. 8 Although there are no guidelines or consensus statements regarding intraoperative periprocedural 67 Neural injury 68 Infection (0%-28% EVD, 0%-50% LD) 8,69-75 Malposition 2,76 Occlusion and malfunction [77][78][79] Overdrainage of CSF Subdural or epidural hematoma [80][81][82][83] Rebleeding from a ruptured cerebral aneurysm 84 Intracranial hypotension [85][86][87] Cerebellar tonsillar herniation 79,[88][89][90][91] Paradoxical herniation 92 Pneumocephalus 79,93 Iatrogenic vascular injury (arteriovenous fistula, cerebral pseudoaneurysm) 94 Fracture of catheters, 95 with retained fragment of catheter 96,97 Inadvertent injections of drugs into EVDs [98][99][100][101][102][103][104][105] Postdural puncture headache 106 CSF indicates cerebrospinal fluid; EVD, external ventricular drain; LD, lumbar drain. administration of antibiotics before LD placement for aortic and nonaortic surgery, this task force recommends following standards such as those used for EVD insertion and management.…”

“…However, change in patient position can also lead to CSF overdrainage and result in complications such as rebleeding of intracranial aneurysm, [131][132][133] subdural hemorrhage from disruption of bridging veins, [80][81][82] and reverse brain herniation. 92 Anesthesiology providers are often involved in the transport of these patients to and from the ICU and to angiography and/or to and from the OR. There are no guidelines regarding EVD management during IHT.…”