Brain herniation in a patient with apparently normal intracranial pressure: a case report

Mats B Dahlqvist,Stephan M Jakob,Robert H Andres,Jukka Takala,Andreas Raabe,Martin W Dünser

doi:10.1186/1752-1947-4-297

Mats B Dahlqvist, Stephan M Jakob + Show 4 more

Open Access

https://doi.org/10.1186/1752-1947-4-297

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Abstract

IntroductionIntracranial pressure monitoring is commonly implemented in patients with neurologic injury and at high risk of developing intracranial hypertension, to detect changes in intracranial pressure in a timely manner. This enables early and potentially life-saving treatment of intracranial hypertension.Case presentationAn intraparenchymal pressure probe was placed in the hemisphere contralateral to a large basal ganglia hemorrhage in a 75-year-old Caucasian man who was mechanically ventilated and sedated because of depressed consciousness. Intracranial pressures were continuously recorded and never exceeded 17 mmHg. After sedation had been stopped, our patient showed clinical signs of transtentorial brain herniation, despite apparently normal intracranial pressures (less than 10 mmHg). Computed tomography revealed that the size of the intracerebral hematoma had increased together with significant unilateral brain edema and transtentorial herniation. The contralateral hemisphere where the intraparenchymal pressure probe was placed appeared normal. Our patient underwent emergency decompressive craniotomy and was tracheotomized early, but did not completely recover.ConclusionsIntraparenchymal pressure probes placed in the hemisphere contralateral to an intracerebral hematoma may dramatically underestimate intracranial pressure despite apparently normal values, even in the case of transtentorial brain herniation.

Highlights

Intracranial pressure monitoring is commonly implemented in patients with neurologic injury and at high risk of developing intracranial hypertension, to detect changes in intracranial pressure in a timely manner
Intraparenchymal pressure probes placed in the hemisphere contralateral to an intracerebral hematoma may dramatically underestimate intracranial pressure despite apparently normal values, even in the case of transtentorial brain herniation
We present a patient who experienced transtentorial brain herniation despite an apparently normal intracranial pressure (ICP)

Summary

Introduction

Elevated supratentorial intracranial pressure (ICP) can cause transtentorial brain herniation, leading to cerebral hypoperfusion, brainstem herniation, and death, if left untreated [1]. Case presentation A 75-year-old Caucasian man with chronic arterial hypertension, hyperlipidemia and chronic obstructive pulmonary disease presented to the emergency department with right-sided hemiplegia and facial nerve paresis, global aphasia and gaze deviation to the left. His level of consciousness was depressed (Glasgow Coma Scale 11) and arterial blood pressure was elevated (200/ 90 mmHg). After admission to the intensive care unit, our patient’s level of consciousness further deteriorated (Glasgow Coma Scale 6) and he had to be intubated to protect his airway Since he could not be clinically evaluated due to sedation required for endotracheal tube tolerance and mechanical ventilation, ICP monitoring was indicated. When he entered long-term neurologic rehabilitation another ten days later, his neurologic function of our patient remained impaired (right-sided hemiparesis, Glasgow Coma Scale 10 to 11, no communication possible)

Discussion

Conclusions