Du C, Tang HJ, Fan SM. Paradoxical herniation after decompressive craniectomy provoked by mannitol: A case report. World J Clin Cases 2022; 10(15): 4917-4922 [PMID: 35801057 DOI: 10.12998/wjcc.v10.i15.4917]
Corresponding Author of This Article
Shuang-Ming Fan, MD, Attending Doctor, Neurosurgery, The Affiliated Hospital of Chengdu University, No. 82, North Section 2, Second Ring Road, Chengdu 610000, Sichuan Province, China. 297551802@qq.com
Research Domain of This Article
Clinical Neurology
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Case Report
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Du C, Tang HJ, Fan SM. Paradoxical herniation after decompressive craniectomy provoked by mannitol: A case report. World J Clin Cases 2022; 10(15): 4917-4922 [PMID: 35801057 DOI: 10.12998/wjcc.v10.i15.4917]
World J Clin Cases. May 26, 2022; 10(15): 4917-4922 Published online May 26, 2022. doi: 10.12998/wjcc.v10.i15.4917
Paradoxical herniation after decompressive craniectomy provoked by mannitol: A case report
Chuan Du, Hua-Juan Tang, Shuang-Ming Fan
Chuan Du, Shuang-Ming Fan, Neurosurgery, the Affiliated Hospital of Chengdu University, Chengdu 610000, Sichuan Province, China
Hua-Juan Tang, Neurology, West China Hospital, Sichuan University, Chengdu 610000, Sichuan Province, China
Author contributions: Du C and Tang HJ designed this work, analyzed the data, and wrote the manuscript; Du C collected the patient's clinical data; Fan SM and Du C performed the surgery; Fan SM designed and reviewed this paper; all authors have read and approved the final version of this manuscript.
Supported bythe Natural Science Project of Chengdu University Clinical School, No. 2020YYZ18.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Shuang-Ming Fan, MD, Attending Doctor, Neurosurgery, The Affiliated Hospital of Chengdu University, No. 82, North Section 2, Second Ring Road, Chengdu 610000, Sichuan Province, China. 297551802@qq.com
Received: September 19, 2021 Peer-review started: September 19, 2021 First decision: December 10, 2021 Revised: December 20, 2021 Accepted: April 3, 2022 Article in press: April 3, 2022 Published online: May 26, 2022 Processing time: 246 Days and 21.8 Hours
Abstract
BACKGROUND
Paradoxical transtentorial herniation is a rare but life-threatening complication of cerebrospinal fluid drainage in patients with large decompressive craniectomy. However, paradoxical transtentorial herniation after rapid intravenous infusion of mannitol has not been reported yet.
CASE SUMMARY
A 48-year-old male suffered from a right temporal vascular malformation with hemorrhage. In a coma, the patient was given emergency vascular malformation resection, hematoma removal, and the right decompressive craniectomy. The patient woke up on the 1st d after the operation and was given 50 g of 20% mannitol intravenously every 8 h without cerebrospinal fluid drainage. On the morning of the 7th postoperative day, after 50 g of 20% mannitol infusion in the Fowler’s position, the neurological function of the patient continued to deteriorate, and the right pupils dilated to 4 mm and the left to 2 mm. Additionally, computed tomography revealed an increasing midline shift and transtentorial herniation. The patient was placed in a supine position and given 0.9% saline intravenously. A few hours later, the patient was fully awake with purposeful movements on his right side and normal communication.
CONCLUSION
Paradoxical herniation may occur, although rarely, after infusing high-dose mannitol intravenously in the Fowler’s position in the case of a large craniectomy defect. An attempt should be made to place the patient in the supine position because this simple maneuver may be life-saving. Do not use high-dose mannitol when the flap is severely sunken.
Core Tip: The paradoxical herniation is a rare but life-threatening complication in patients with large decompressive craniectomies. This case report suggests that mannitol treatment after a large decompressive craniectomy can cause a paradoxical herniation. Early recognition and proper treatment can save a patient's life.
