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Reverse brain herniation during posterior fossa surgery
Hemanshu Prabhakar1, G Umesh, R S Chouhan
1Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
Insights
Posterior fossa tumors can cause obstructive hydrocephalus. Rapid cerebrospinal fluid drainage during surgery can lead to reverse brain herniation, a rare but serious complication successfully managed with saline injection.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Critical Care Medicine
Background:
- Posterior fossa tumors frequently cause obstructive hydrocephalus, necessitating cerebrospinal fluid (CSF) diversion.
- Surgical intervention for these tumors carries a risk of intracranial pressure (ICP) fluctuations.
- Rapid CSF drainage can precipitate paradoxical brain herniation, known as reverse coning.
Observation:
- A 5-year-old male with a posterior fossa tumor and hydrocephalus underwent craniectomy in the prone position.
- An intraventricular shunt catheter was placed post-craniotomy to decompress the brain.
- The patient experienced sudden, severe bradycardia and asystole, indicative of reverse coning.
Findings:
- Reverse coning was diagnosed following rapid CSF drainage.
- Prompt intraventricular injection of 10-15 mL normal saline reversed the bradycardia and asystole.
- The patient's cardiac rhythm spontaneously returned to sinus rhythm.
Implications:
- This case highlights the critical risk of reverse coning during CSF diversion in posterior fossa surgery.
- Intraventricular saline injection is a potentially life-saving, rapid intervention for reverse coning.
- Neurosurgeons must be vigilant for and prepared to manage this rare but dangerous complication.
Abstract:
Posterior fossa tumors are commonly associated with obstructive hydrocephalus. Relieving the raised intracranial pressure by draining the cerebrospinal fluid presents the possibility of reverse herniation of the brain. A 5-year-old male child with a diagnosis of posterior fossa space-occupying lesion and hydrocephalus was scheduled for craniectomy in the prone position. After craniectomy, the surgeons placed an intraventricular shunt catheter to drain out cerebrospinal fluid in an attempt to reduce the tense brain so as to facilitate easy dissection of the tumor. The patient had sudden and severe bradycardia followed by asystole. A diagnosis of reverse coning was made. Immediately, the surgeon injected 10-15 mL normal saline into the ventricles. There was a spontaneous return of the sinus rhythm and the rest of the course of surgery was uneventful. We present this case showing a rare phenomenon and its successful management.