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

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.

Paradoxical herniation after decompressive craniectomy provoked by mannitol: A case report

“…Paradoxical herniation has been reported after craniotomy in the context of CSF hypovolemia, usually ascribed to intraoperative or postoperative CSF drainage or spinal CSF fistula[ 1 , 3 - 5 ]. Currently, only a few cases have been reported that paradoxical herniation may occur in the absence of CSF drainage, which is somewhat different from our case[ 6 - 8 ]. We describe a unique case of spontaneous paradoxical herniation after intravenous infusion of mannitol and decompressive craniectomy.…”

“…Paradoxical herniation, a rare complication of patients who have undergone craniotomy, refers to transtentorial herniation in the context of intracranial hypotension[ 3 , 6 ]. This life-threatening complication has been reported after various types of CSF depletion and drainage, including CSF leakage, lumbar puncture, lumbar drain, CSF shunt, and ventriculostomy in patients undergoing a decompressive craniectomy[ 4 , 9 - 11 ].…”

“…This life-threatening complication has been reported after various types of CSF depletion and drainage, including CSF leakage, lumbar puncture, lumbar drain, CSF shunt, and ventriculostomy in patients undergoing a decompressive craniectomy[ 4 , 9 - 11 ]. The pathological mechanism of this rarely reported complication is unclear and may be related to atmospheric pressure, cerebral gravity, positional changes, and CSF exhaustion[ 3 , 6 , 7 ]. Interestingly, there are many reports of sinking skin flap syndromes after large craniectomy, with a series of symptoms, including motor dysfunction, cognitive dysfunction, headache, mood disorders, and sensory disturbance, most of which can be improved by cranioplasty[ 12 , 13 ].…”

“…If a patient begins rebleeding after intracranial hematoma removal, reoperation should be performed to remove the hematoma and cranioplasty; if paradoxical herniation occurs after surgery, the possibility of CSF loss during multiple operations should be considered[ 8 ]. Another report of paradoxical herniation that occurred 1 h after removing acute subdural hematoma was suspected to be due to the loss of a large amount of CSF during the operation; the patient improved after an immediate cranioplasty[ 6 ]. Interestingly, a patient with massive cerebral infarction caused by middle cerebral artery embolization developed paradoxical herniation 8 d after decompressive craniectomy, and the neurological function in the upright position continued to deteriorate.…”

“…In addition, by clamping all CSF drainage tubes or performing CSF leakage repair to solve the underlying cause of CSF loss, clinical improvement is usually expected within a few hours[ 4 ]. Emergency cranioplasty is also a treatment option[ 6 ].…”