Acute Paradoxical Herniation Secondary to Epidural Overdrainage Following Unilateral Decompressive Craniectomy:A Case Report

LU Chanrong; PENG Ruoyu; LIU Hongchao

doi:10.13798/j.issn.1009-153X.2025.11.015

Abstract：Paradoxical herniation is a relatively rare clinical condition.This article reports a case of acute paradoxical herniation caused by epidural overdrainage following unilateral decompressive craniectomy.The patient was a 75-year-old male admitted due to drowsiness for 3 hours after a traffic accident.On admission,his Glasgow Coma Scale(GCS)score was 14,and a cranial CT scan showed left frontotemporal contusion and laceration accompanied by subdural and epidural hematomas,with the ambient cistern preserved.Two hours post-admission,his consciousness deteriorated,with a GCS score of 11.An immediate repeat CT scan revealed hematoma expansion,compression of the ambient cistern,and a midline shift of 7 mm.An emergency left decompressive craniectomy and intracranial hematoma evacuation were performed.Postoperatively,intravenous infusion of 20%mannitol and cerebrospinal fluid(CSF)drainage were initiated.At 37 hours post-surgery,the patient gradually progressed to coma with a GCS score of 7.A repeat CT scan showed left subdural accumulation of blood and air,significant scalp sinking,a midline shift to the left of approximately 13 mm,and marked compression of the ambient cistern.A diagnosis of acute paradoxi-cal herniation following decompressive craniectomy was made.The drainage tube was promptly removed,mannitol administra-tion was stopped,and rapid fluid resuscitation was initiated.Following treatment,the patient's consciousness gradually improved.Three months after discharge,the patient underwent cranioplasty at another hospital.At the 9-month follow-up,the outcome was favorable with a Glasgow Outcome Scale(GOS)score of 5.This case suggests that after decompressive craniectomy,a history of substantial CSF drainage combined with unexplained impaired consciousness,sunken bone flap,and signs of increased intra-cranial pressure should raise suspicion for paradoxical herniation.The therapeutic goal is to increase intracranial pressure.