Prolonged lumbar spinal drainage after the resection of tumors of the skull base: a cautionary note

A combined transcranial and facial approach was used for an en bloc resection of a malignant angiosarcoma of the ethmoid sinuses. The patient awoke neurologically intact and was monitored in the Intensive Care Unit. A lumbar subarachnoid drain was placed for the continuous removal of the cerebrospinal fluid (CSF). Approximately 36 hours after surgery, she deteriorated neurologically and demonstrated bilateral extensor posturing to painful stimuli. A computed tomographic scan demonstrated obliteration of the basal cisterns indicative of transtentorial herniation and a small amount of extradural air. Eight hours after the lumbar drain was turned off, the patient had recovered completely. We propose that the patient manifested transtentorial herniation caused by a pressure gradient between the supratentorial and lumbar cistern compartments brought on by the continuous removal of CSF from the lumbar subarachnoid space. We suggest that ventricular drainage should be considered for these cases rather than lumbar drainage. This offers the same advantage of removing the CSF and maintaining low-to-normal intracranial pressure without the risk of transtentorial herniation.