Cisternal Overdrainage of Cerebrospinal Fluid Can Cause Upward Transtentorial Herniation
Ryota Mashiko, Yasushi Shibata
Mito Medical Center, Tsukuba University Hospital
Department of Neurosurgery, Mito Kyodo General Hospital
3-2-7 Miya-Machi, Mito, Ibaraki 310-0015, Japan
- *Corresponding author: Ryota Mashiko, MD, PhD, Mito Medical Center, Tsukuba University Hospital, Department of Neurosurgery, Mito Kyodo General Hospital, 3-2-7 Miya-Machi, Mito, Ibaraki 310-0015, Japan, Tel: +81-29-231-2371, Fax: +81-29-231-5137, E-mail: firstname.lastname@example.org
Transtentorial upward herniation, Cisternal drainage, Subarachnoid hemorrhage, Vasospasm Overdrainage
Upward Herniation due to Cisternal Overdrainage
Cerebral vasospasm has long been thought to be positively correlated with the hematoma volume in patients with subarachnoid hemorrhage (SAH).1) Some authors have reported that cisternal drainage of bloody cerebrospinal fluid (CSF) effectively prevented subsequent cerebral vasospasm.2,3) Drainage techniques include cisternal,2,3) lumbar,4) and external ventricular drainage (EVD).5) Cisternal drainage and continuous irrigation with urokinase is considered an effective treatment method in Japan.6) Simple cisternal CSF drainage is also employed. However, any technique that causes rapid changes in the circulatory dynamics of the CSF may result in various complications. To the best of our knowledge, no previous reports have described upward transtentorial herniation caused by overdrainage of CSF via a cisternal drain in patients with SAH. Clinicians should be aware of the possibility of upward transtentorial herniation caused by cisternal overdrainage of CSF. Therefore, we herein describe such a case.
A 59-year-old woman was transported to our hospital with sudden unconsciousness and severe headache. Head computed tomography (CT) and three-dimensional CT angiography revealed SAH (Fig. 1) and a left internal carotid artery–posterior communicating artery aneurysm. Her condition was diagnosed as Fisher 3 aneurysmal SAH, World Federation of Neurosurgeons grade 2. She underwent emergent neck clipping of the aneurysm with left frontotemporal craniotomy. We performed third ventriculostomy via fenestration of the lamina terminalis to control the intracranial pressure during the operation. After uneventful clipping, a cisternal drain tube was inserted into the left carotid cistern. The Liliequist membrane was not opened.
The patient was awake and alert the day after the surgery. We started cisternal drainage via the intraoperatively placed drain with 5 cm H2O pressure. The volume of CSF obtained ranged from 300 to 400 ml per day.
On the fifth day after surgery, the patient’s consciousness started to decline, and on the sixth day, she exhibited a level of consciousness consistent with a Glasgow Coma Scale score of 7 with no focal deficits. Head CT revealed shrinkage of the bilateral lateral ventricles and narrowing of the supracerebellar subarachnoid space, indicating upward transtentorial herniation (Fig. 2). Digital subtraction angiography on the same day showed no sign of vasospasm.
We strongly suspected that this condition was caused by overdrainage of CSF via the cisternal drain. We therefore decreased the volume of CSF drainage to 50 ml per day by adjusting the drainage pressure and extracted the drain on postoperative day 10. At that time, CT revealed resolution of the upward transtentorial herniation (Fig. 3). The patient’s consciousness fully recovered.
The patient developed no sequelae and needed no other surgical interventions. She was discharged on hospitalization day 76 and was able to return to her work. She remained clinically well for 18 months after hospital discharge.
Vasospasm after SAH is a major cause of severe morbidity. Removal of the clot in the arachnoid space, which is the main cause of vasospasm, has been attempted in various ways. However, changes in the circulatory dynamics of CSF by any drainage technique may cause occasional complications.
EVD in patients with SAH, which causes upward transtentorial herniation and leads to dorsal mesencephalic syndrome, has been reported.7) Antes et al.8) described cases of overdrainage of ventricular CSF resulting in upward transtentorial herniation associated with dorsal mesencephalic syndrome in patients who underwent EVD. In these cases, the patients’ symptoms were eradicated by endoscopic third ventriculostomy. On the other hand, lumbar drainage in a patient with SAH caused tonsillar herniation in spite of a small CSF drainage volume.9)
Our case is the first report of upward transtentorial herniation caused by overdrainage of CSF via a cisternal drain in a patient with SAH. The pathophysiology is unclear. Of course, the drainage volume of CSF in our case was much higher than that in other reported cases, which described an adequate drainage volume of about 5 to 10 ml/hr2 or 150 ml/day.10) It is possible that a large amount of drained CSF via the subarachnoid space and fenestrated third ventricle together with an intact Liliequist membrane caused rapid formation of a large pressure gap between the supra- and infratentorial space.
Simultaneous minute symptomatic vasospasm cannot be completely ruled out in this case because a more detailed cerebral blood flow study was not performed and the patient only showed unconsciousness among several possible signs of upward tentorial herniation. However, upward tentorial herniation should not be excluded because it can easily be corrected by adjusting the volume of CSF drainage. In addition, the left thin epidural hematoma under the bone flap remained as the upward herniation developed, demonstrating that the hematoma was not significantly associated with the past stupor.
In conclusion, cisternal drainage is frequently adopted in neck clipping surgery for ruptured aneurysms; therefore, knowledge of this complication is essential.
We state all authors have no actual or potential conflicts of interest with regard to the manuscript submitted for review and have registered online Self-reported COI Disclosure Statement Forms through the website for JNS members.
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CT on admission showed (A) diffuse SAH and (B) a scar in the left putamen region, indicating old cerebrovascular disease.
CT 5 days after surgery showed (A) upward transtentorial herniation and (B) shrinkage of the bilateral lateral ventricles. The hindbrain was shifted upward and the quadrigeminal cistern had disappeared. A left thin epidural hematoma with a slight mass effect was seen under the bone flap.
CT 10 days after surgery at the same scanning level as CT 5 days after surgery showed (A) resolution of the upward transtentorial herniation and (B) shrinkage of the bilateral lateral ventricles. Note that the left thin epidural hematoma under the bone flap remained as the upward herniation developed.