J Korean Neurosurg Soc.  2012 Feb;51(2):102-104. 10.3340/jkns.2012.51.2.102.

Paradoxical Transtentorial Herniation Caused by Lumbar Puncture after Decompressive Craniectomy

  • 1Department of Internal Medicine, School of Medicine, Chosun University, Gwangju, Korea.
  • 2Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, Korea. ns64902@hanmail.net


Although decompressive craniectomy is an effective treatment for various situations of increased intracranial pressure, it may be accompanied by several complications. Paradoxical herniation is known as a rare complication of lumbar puncture in patients with decompressive craniectomy. A 38-year-old man underwent decompressive craniectomy for severe brain swelling. He remained neurologically stable for five weeks, but then showed mental deterioration right after a lumbar puncture which was performed to rule out meningitis. A brain computed tomographic scan revealed a marked midline shift. The patient responded to the Trendelenburg position and intravenous fluids, and he achieved full neurologic recovery after successive cranioplasty. The authors discuss the possible mechanism of this rare case with a review of the literature.


Paradoxical herniation; Decompressive craniectomy; Lumbar puncture; Cranioplasty

MeSH Terms

Brain Edema
Decompressive Craniectomy
Head-Down Tilt
Intracranial Pressure
Spinal Puncture


  • Fig. 1 Initial computed tomography scan shows hemorrhagic contusion in the right fronto-temporo-parietal region with severe brain swelling and epidural hematoma in the left temporo-occipital region.

  • Fig. 2 After emergent right fronto-temporo-parietal craniectomy operation, brain computed tomographic scan shows the removal of epidural hematoma and improvement of brain swelling.

  • Fig. 3 Computed tomographic scan taken five weeks postoperatively and just before lumbar puncture shows no midline shift.

  • Fig. 4 Brain computed tomographic scan after lumbar puncture reveals midline shift to the left and transtentorial herniation.

  • Fig. 5 Brain computed tomographic scan after Trendelenberg position and sufficient intravenous hydration shows the restoration of the midline.

  • Fig. 6 Brain computed tomographic scan after cranioplasty shows complete resolution of midline shift.


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