In-hospital unexpected cerebral herniation-New neurosurgical quality control standards: A case report

In-hospital unexpected cerebral herniation (IHUCH) refers to abrupt, unanticipated cerebral herniation in patients who were previously considered stable. Its sudden onset may lead to delayed recognition and poor outcomes.

A 50-year-old man was transferred to our institution after a motor vehicle collision. The patient's Glasgow Coma Scale score remained between 13 and 14 upon admission. At the sixth day, without warning, he acutely lost consciousness, dropping to Glasgow Coma Scale 6, with left pupillary dilatation and loss of light reflex.

Initial computed tomography revealed: left frontotemporal traumatic subdural hemorrhage, right-sided epidural hemorrhage, traumatic subarachnoid hemorrhage, right temporal bone fracture, left traumatic intraparenchymal hematoma, pneumocephalus, and basal skull fracture. Without surgical indications, day 6 emergency computed tomography demonstrated the compression of the left lateral ventricle with rightward midline shift, effacement of the suprasellar cistern and perimesencephalic cisterns, and marked cerebral edema.

Urgent left decompressive craniectomy with evacuation of subdural hematoma was performed. Postoperatively, the patient's intracranial hypertension remained refractory. As conservative measures failed, a contralateral decompressive craniectomy was performed the next day, opposite the initial surgical site.

Despite prompt surgical decompression, the patient remained in a persistent comatose state. After 5 months of comprehensive neuro-rehabilitation without neurological improvement, the family elected to withdraw life-sustaining treatment and the patient was discharged home.

This case illustrates how IHUCH can occur even under close neuro-monitoring. Key risk factors include postoperative hematoma recurrence, bilateral frontal lobe contusions, delayed traumatic intracranial hematoma, paradoxical cerebral herniation, chronic subdural hygroma, and tumor. Integrating IHUCH into neurosurgical quality control standards, augmented by continuous multimodal intracranial pressure monitoring, may enhance early detection and improve outcomes.