title: Paradoxical Herniation After Unilateral Decompressive Craniectomy Predicts Better Patient Survival: A Retrospective Analysis of 429 Cases.
abstract: Paradoxical herniation (PH) is a life-threatening emergency after decompressive craniectomy. In the current study, we examined patient survival in patients who developed PH after decompressive craniectomy versus those who did not. Risk factors for, and management of, PH were also analyzed. This retrospective analysis included 429 consecutive patients receiving decompressive craniectomy during a period from January 2007 to December 2012. Mortality rate and Glasgow Outcome Scale (GOS) were compared between those who developed PH (n = 13) versus those who did not (n = 416). A stepwise multivariate logistic regression analysis was carried out to examine the risk factors for PH. The overall mortality in the entire sample was 22.8%, with a median follow-up of 6 months. Oddly enough, all 13 patients who developed PH survived beyond 6 months. Glasgow Coma Scale did not differ between the 2 groups upon admission, but GOS was significantly higher in subjects who developed PH. Both the disease type and coma degree were comparable between the 13 PH patients and the remaining 416 patients. In all PH episodes, patients responded to emergency treatments that included intravenous hydration, cerebral spinal fluid drainage discontinuation, and Trendelenburg position. A regression analysis indicated the following independent risk factors for PH: external ventriculostomy, lumbar puncture, and continuous external lumbar drainage. The rate of PH is approximately 3% after decompressive craniectomy. The most intriguing findings of the current study were the 0% mortality in those who developed PH versus 23.6% mortality in those who did not develop PH and significant difference of GOS score at 6-month follow-up between the 2 groups, suggesting that PH after decompressive craniectomy should be managed aggressively. The risk factors for PH include external ventriculostomy, ventriculoperitoneal shunt, lumbar puncture, and continuous external lumbar drainage.
authors.affiliation: From the Department of Neurosurgery, Fuzhou General Hospital of Nanjing Command, PLA, Fuzhou (WC, SW); Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, Shantou (WC, JG, JW, GP, YY); Department of Neurosurgery, Jieyang People's Hospital, Jieyang (MH); and Department of Neurosurgery (CC), Shantou Central Hospital, Shantou, Guangdong, China.
authors.forename: Weiqiang
authors.initials: W
authors.lastname: Chen
authors.forename: Jingfang
authors.initials: J
authors.lastname: Guo
authors.forename: Jin
authors.initials: J
authors.lastname: Wu
authors.forename: Guoyi
authors.initials: G
authors.lastname: Peng
authors.forename: Mindong
authors.initials: M
authors.lastname: Huang
authors.forename: Chuwei
authors.initials: C
authors.lastname: Cai
authors.forename: Yingming
authors.initials: Y
authors.lastname: Yang
authors.forename: Shousen
authors.initials: S
authors.lastname: Wang
mesh_terms: D000368:Aged; D001930:Brain Injuries / Q000601:surgery*; D056424:Decompressive Craniectomy / Q000009:adverse effects / Q000379:methods; D004677:Encephalocele / Q000175:diagnosis / Q000401:mortality; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D019586:Intracranial Hypertension / Q000175:diagnosis / Q000209:etiology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed