Chen Shanwen, Wang Lu, Kang Quanli
Department of Neurosurgery, Beijing Shunyi District Hospital, Capital Medical University, Beijing, 101300, China.
Neurol Sci. 2025 Apr;46(4):1765-1775. doi: 10.1007/s10072-024-07940-8. Epub 2024 Dec 12.
Critical cerebrospinal fluid hypovolemia (CCSFH) is a rare postcraniotomy condition in patients with acute supratentorial brain injury, often mistaken for intracranial hypertension. This article aims to enhance awareness of CCSFH by describing its clinical and radiological characteristics.
Between January 2019 and November 2023, 330 consecutive patients with acute critical brain injury underwent supratentorial craniotomy. CCSFH diagnosis was based on three criteria: a decline in consciousness, head CT scans revealing midline shift of ≥ 5 mm, and rapid clinical or imaging presentation improvement within three days after implementing various treatments to increase CSF volume. Clinical and imaging features, treatment courses, and responses were analyzed. Midline shift on head CT scans was measured at four time points before and after surgery and compared using repeated measures ANOVA.
Fifteen patients (4.5%) developed CCSFH within 1 to 13 days post-surgery. Of them, seven patients exhibited a decline in consciousness or mental status, with three presenting anisocoria. The remaining eight had normal pupil sizes, complicating consciousness assessment due to postoperative sedation and analgesia. The average midline shift was 10.84 ± 2.83 mm during the CCSFH presentation, which showed a statistically significant difference from the initial postoperative measurement (p = 0.005) but not from the preoperative measurement (p = 0.536). Intracranial pressure ranged from 1-11 mmHg in five cases. The first four cases underwent an unplanned decompressive craniectomy as their conditions progressed to severe cingulate or transtentorial herniation, attributable to unawareness of cerebrospinal fluid hypovolemia before the second surgery. Drawing from the accumulated experiences, the subsequent eleven cases of CCSFH were promptly identified upon onset, and appropriate treatments were administered, with the supine position serving as the primary intervention modality. The CCSFH condition was successfully reversed in all patients.
CCSFH after craniotomy should be considered, and prompt identification and intervention are required in cases of clinical deterioration. The primary management strategy is placing the patient supine, along with stopping cerebrospinal fluid drainage, halting hyperosmotic diuretics, and administering intravenous hydration, often leading to favorable outcomes.
严重脑脊液容量减少（CCSFH）是急性幕上脑损伤患者开颅术后一种罕见的情况，常被误诊为颅内高压。本文旨在通过描述其临床和影像学特征，提高对CCSFH的认识。
2019年1月至2023年11月，连续330例急性重症脑损伤患者接受幕上开颅手术。CCSFH诊断基于三个标准：意识下降、头部CT扫描显示中线移位≥5mm，以及在采取各种增加脑脊液容量的治疗措施后三天内临床或影像学表现迅速改善。分析临床和影像学特征、治疗过程及反应。在手术前后的四个时间点测量头部CT扫描的中线移位，并使用重复测量方差分析进行比较。
15例患者（4.5%）在术后1至13天发生CCSFH。其中，7例患者意识或精神状态下降，3例出现瞳孔不等大。其余8例瞳孔大小正常，由于术后镇静和镇痛，意识评估变得复杂。CCSFH出现时平均中线移位为10.84±2.83mm，与术后初始测量相比有统计学显著差异（p = 0.005），但与术前测量无差异（p = 0.536）。5例患者颅内压范围为1 - 11mmHg。前4例患者由于在第二次手术前未意识到脑脊液容量减少，病情进展为严重的扣带回或小脑幕切迹疝，因此接受了计划外的减压性颅骨切除术。根据积累的经验，随后的11例CCSFH病例在发病时被及时识别，并给予了适当的治疗，主要干预方式为仰卧位。所有患者的CCSFH情况均成功逆转。
开颅术后应考虑CCSFH，临床病情恶化时需及时识别并进行干预。主要管理策略是让患者仰卧，同时停止脑脊液引流、停用高渗利尿剂并给予静脉补液，通常会取得良好效果。
