Lumbar puncture as possible cause of sudden paradoxical herniation in patient with previous decompressive craniectomy: report of two cases

Liang Shen, Sheng Qiu, Zhongzhou Su, Xudong Ma, Renfu Yan

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. 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. 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.