Yamada Shoko M, Iwamoto Naotaka, Tomita Yusuke, Takeda Ririko, Nakane Makoto
Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN.
Cureus. 2023 Aug 29;15(8):e44355. doi: 10.7759/cureus.44355. eCollection 2023 Aug.
It is not rare that progressive hydrocephalus worsens clinical conditions in a patient with external decompression and drainage or shunt surgery is required. However, spinal drainage or shunt surgeries potentially carry a risk of causing paradoxical herniation in a patient with decompressive craniectomy, particularly in a comatose case with wide craniectomy. Careful and strict observations are necessary for such patients. In our three comatose cases with craniectomy, paradoxical herniation occurred due to excessive drainage after 5-7 days of shunt surgery and lumbar drainage, although the drainage pressure was set at more than 10 cmHO. Fortunately, in the three cases, the herniation improved within a few days after the drain was clamped and the bed was flattened. However, the Trendelenburg position and epidural blood patch might be necessary if paradoxical herniation occurs acutely after lumbar puncture or drainage because delayed resolution can be fatal in the herniation.
对于接受了外部减压引流或分流手术的患者，进行性脑积水使临床状况恶化的情况并不罕见，此时可能需要进行脊柱引流或分流手术。然而，脊柱引流或分流手术在接受去骨瓣减压术的患者中存在导致反常疝的风险，尤其是在进行了广泛去骨瓣减压术的昏迷患者中。对此类患者进行仔细和严格的观察是必要的。在我们的三例昏迷去骨瓣减压术患者中，尽管引流压力设定在10 cmHO以上，但在分流手术和腰椎引流5 - 7天后，由于过度引流出现了反常疝。幸运的是，在这三例患者中，在夹闭引流管并放平病床后的几天内，疝有所改善。然而，如果在腰椎穿刺或引流后急性发生反常疝，可能需要采用头低脚高位和硬膜外血贴，因为疝的延迟消退可能是致命的。
