title: Paradoxical cerebral herniation secondary to lumbar puncture after decompressive craniectomy for a large space-occupying hemispheric stroke: case report.
abstract: OBJECTIVE
  The risk of transtentorial herniation after removal of cerebrospinal fluid from the lumbar cistern in the setting of a supratentorial lesion with significant mass effect, increased cerebrospinal fluid pressure, or midline shift is well known. We report a case of cerebral herniation from intracranial hypotension (so-called paradoxical herniation) secondary to a lumbar puncture 1 month after decompressive hemicraniectomy for a large right hemispheric stroke.
  
  
  METHODS
  A 50-year-old woman was transferred to our neurosurgical service for obtundation 4 days after a lumbar puncture to rule out meningitis and 1 month after decompressive craniectomy for a large right hemispheric stroke.
  
  
  METHODS
  Eighty grams of mannitol was administered before transfer. On arrival at our hospital, the patient was intubated and a computed tomographic scan was performed. The patient was diagnosed with low-pressure herniation after review of the computed tomographic scan. Rehydration was initiated, and the patient was placed in the Trendelenburg position. She became easier to arouse, but her pupils remained dilated. She experienced a sudden severe cardiac arrhythmia leading to a cardiac arrest. Attempted resuscitation was unsuccessful, and the patient was pronounced dead.
  
  
  CONCLUSIONS
  Lumbar punctures may result in lethal intracranial hypotension in patients after hemicraniectomy and are thus contraindicated unless care is taken to remove the pressure gradient of atmospheric air across the lumbar cistern.
authors.affiliation: Department of Neurosurgery, Stanford University Medical Center, Stanford, California 94305-5327, USA.
authors.forename: Adetokunbo A
authors.initials: AA
authors.lastname: Oyelese
authors.forename: Gary K
authors.initials: GK
authors.lastname: Steinberg
authors.forename: Stephen L
authors.initials: SL
authors.lastname: Huhn
authors.forename: Christine A C
authors.initials: CA
authors.lastname: Wijman
mesh_terms: D002533:Cerebral Angiography; D015170:Cerebrospinal Fluid Pressure / Q000502:physiology; D003399:Craniotomy / Q000379:methods*; D019299:Decompression, Surgical; D007839:Functional Laterality; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008579:Meningioma / Q000150:complications / Q000601:surgery; D008875:Middle Aged; D009460:Neurologic Examination / Q000379:methods; D013129:Spinal Puncture / Q000379:methods*; D020521:Stroke / Q000209:etiology / Q000601:surgery; D013345:Subarachnoid Hemorrhage