Published online May 26, 2022. doi: 10.12998/wjcc.v10.i15.4917
Peer-review started: September 19, 2021
First decision: December 10, 2021
Revised: December 20, 2021
Accepted: April 3, 2022
Article in press: April 3, 2022
Published online: May 26, 2022
Paradoxical transtentorial herniation is a rare but life-threatening complication of cerebrospinal fluid drainage in patients with large decompressive craniectomy. However, paradoxical transtentorial herniation after rapid intravenous infusion of mannitol has not been reported yet.
A 48-year-old male suffered from a right temporal vascular malformation with hemorrhage. In a coma, the patient was given emergency vascular malformation resection, hematoma removal, and the right decompressive craniectomy. The patient woke up on the 1st d after the operation and was given 50 g of 20% mannitol intravenously every 8 h without cerebrospinal fluid drainage. On the morning of the 7th postoperative day, after 50 g of 20% mannitol infusion in the Fowler’s position, the neurological function of the patient continued to deterio
Paradoxical herniation may occur, although rarely, after infusing high-dose mannitol intravenously in the Fowler’s position in the case of a large craniectomy defect. An attempt should be made to place the patient in the supine position because this simple maneuver may be life-saving. Do not use high-dose mannitol when the flap is severely sunken.
Core Tip: The paradoxical herniation is a rare but life-threatening complication in patients with large decompressive craniectomies. This case report suggests that mannitol treatment after a large decompressive craniectomy can cause a paradoxical herniation. Early recognition and proper treatment can save a patient's life.