Hydrocephalus and ex-vacuo ventricular dilatations which cause persistent brain herniation with impossibility to perform cranioplasty, are well known late complications after decompressive hemicraniectomy; concerning the physiopathologic mechanism leading to these complications, there are several theories. We report the particular case of a patient suffering from persistent brain herniation after decompressive hemicraniectomy, due to development of subdural hygroma, intraparenchymal multiple liquoral cysts and only mild enlargement of frontal horn of right lateral ventricle. A fifty-five years old male patient was treated with decompressive right hemicraniectomy for acute hemispheric swelling consequent to right internal carotid artery dissecation. After several months, evaluating the patient for cranioplasty, brain herniation was clinically evident and brain MRI confirmed it due to subdural hygroma, intraparenchymal multiple liquoral cysts and mild enlargement of frontal horn of right lateral ventricle. According to several reported theories, communication between right frontal horn of lateral ventricle, intraparenchymal liquoral cysts and subdural hygroma was supposed, and CSF lumbar drainage was placed. Regression of brain herniation was achieved and cranioplasty was possible; after few days lumbar drainage was removed: neither operative, nor short and long follow-up period complications were observed. Temporary CSF lumbar drainage resulted effective to obtain regression of a particular case of persistent brain herniation developed after decompressive hemicraniectomy; moreover this safe procedure, not previously described to forerun cranioplasty surgery to our knowledge, allowed performing cranioplasty in absence of complications and avoiding temporary or permanent ventricular shunts which present a major rate of risks and possible complications.
Decompressive hemicraniectomy represents a life saving treatment for malignant intracranial hypertension caused by multiple pathologies, as hemispheric cerebral infarction, nontraumatic intraparenchymal hemorrhage, aneurysmal subarachnoid hemorrhage, and venous sinus thrombosis [
A 55 years old male patient had suffered for a right acute hemispheric malignant ischemia caused by right internal carotid artery (ICA) dissecation and consequent right MCA (M1, M2, M3) obstruction, with severe left hemyparesis and coma state due to the consequent massive brain hemispheric swelling. Therefore, he had been treated with a decompressive right hemispheric craniectomy, reacquiring a normal status of consciousness, with permanence of severe left hemiparesis. Because of successive prolonged pulmonary infections, evaluation for cranioplasty was possible only 7 months after surgery, but brain MRI showed the presence of subdural hygroma and multiple intraparenchymal CSF cysts in the right malacic cerebral hemisphere with brain herniation from the craniotomic gap, associated to only mild ex-vacuo dilatation of the frontal horn of the right lateral ventricle; communication between CSF cysts, subdural hygroma, and frontal horn of right lateral ventricle was supposed, according to the MRI (
The patient was first treated with high dosage diuretic therapy without any improvement after several weeks, and cutaneous flap was yet stretched and bulging. Therefore, after nine months from hemicraniectomy, in absence of improvement after diuretic therapy, the patient was admitted to our hospital to consider the necessary treatments for the execution of cranioplasty. Positioning of CSF lumbar drainage was performed, observing an initial pressure of 16 cm H2O; then, 100 ml/die were drained for 3 days before surgery, and daily head bandage to reduce brain herniation was performed. A control brain MRI, after 2 days of drainage, showed a clear volume reduction of CSF cysts and subdural hygroma with reduction of the ventricular frontal horn of lateral ventricle, too; moreover, cutaneous flap became flaccid and concave, and brain herniation regressed. Control of liquoral pressure from lumbar catheter resulted 10 cm H2O. This result confirmed the presence of communication between CSF intraparenchymal cysts, subdural hygroma and frontal horn of right lateral ventricle (
In our reported case we observed a persistent brain herniation until one year after surgery; this particular condi-
tion was due to the contemporary presence of subdural hygroma, marked CSF spaces dilatations (liquoral cysts) and slight enlargement of homolateral frontal horn of lateral ventricle. This occurrence can be explained, in our opinion and according to neuroradiologist, by a pathological anatomic modification subsequent to hemispheric ischemia leading to an ependymal damage with communication between the right frontal horn of lateral ventricle and the described CSF enlarged intersulcal spaces. Regarding the pathologic mechanism by which hydrocephalus/ventricular dilatation and CSF intraparenchymal spaces dilatation develop after hemicraniectomy, it remains to be determined. Some authors [
Temporary CSF lumbar drainage apposition allowed in our patient to eliminate brain herniation, draining daily 100 ml of CSF for three days; moreover, it allowed: to perform cranioplasty avoiding cranial CSF shunts and to restore adeguate CSF flow after cranioplasty. Measurement of CSF pressure from lumbar catheter revealed high value before insertion of lumbar drainage (16 cm H2O), and lower one (10 cm H2O); CSF pressure measurement five days after cranioplasty (two days after closure of lumbar drainage), revealed normal value (12 cm H2O).
Concerning the timing and the expedients for cranioplasty, some authors recommend early cranioplasty [
Temporary CSF lumbar drainage resulted effective to obtain regression of a particular case of persistent brain herniation, developed after decompressive hemicraniectomy, caused by intraparenchymal CSF cysts, subdural hygroma communicating with ventricular system and mild ventricular enlargement; moreover, this safe procedure, not previously described to forerun cranioplasty surgery to our knowledge, allowed performing cranioplasty in absence of complications and avoiding temporary or permanent ventricular shunts.
Mario Francesco Fraioli,Francesco Marzetti,Bernardo Fraioli,Pierpaolo Lunardi, (2016) Persistent Brain Herniation after Decompressive Hemicraniectomy: Role of Lumbar Drainage for Cranioplasty. Case Report. Open Access Library Journal,03,1-6. doi: 10.4236/oalib.1102346