Reverse brain herniation following ventriculoperitoneal shunt
A 45-year-old man presented with occipital headache, blurring of vision, and a tendency to fall, for six months. On examination, the patient was conscious with a pulse rate (PR) of 75/min and blood pressure (BP) of 190/110.The pupils were bilaterally equal and reacting to light. On fundus examination, papilloedema was present. There was sensory loss of the left half of the face and horizontal gaze-evoked nystagmus with fast component to the right. Gait was broadbased with swaying to the left. There were no motor deficits apart from mild spasticity. Magnetic resonance imaging (MRI) of the brain showed right CP angle tumour compressing the brainstem and extending upto the tentorium with severe hydrocephalus. []. An emergency VP shunt was planned. All other investigations were normal. In the operation theatre, the patient was premedicated with 100 μg of fentanyl and 0.2 mg of glycopyrrolate intravenously (IV). Standard monitors of the American Society of Anesthesiologists were used. After induction and intubation of the trachea with 300 mg of thiopentone sodium and 40 mg atracurium IV, anaesthesia was maintained with nitrous oxide, oxygen (50%:50%), and sevoflurane. A right-sided VP shunt (medium pressure) was done and clear CSF which was under high pressure was tapped. Intraoperatively, the BP was high (180–200 mmHg systolic) which was treated with intermittent bolus of 2 mg labetalol IV (total of 14 mg). After extubation, the patient was drowsy but responding to commands with no focal neurological deficits. Two hours after the VP shunt, there was sudden deterioration in the sensorium with both the pupils pinpoint and constricted. His PR was 64/min and BP was 140/90 mmHg. Within a few minutes, the patient became deeply comatose and apnoeic. After emergent reintubation and institution of mechanical ventilation, the shunt tube was blocked in the neck in the intensive care unit to stop further CSF drainage. An MRI scan was done which showed RBH of the midbrain and cerebellum []. One hour later, the patient had regained regular spontaneous respiration, his corneal reflexes were absent, and there was prominent downgaze with upgaze paresis tested by oculocephalic reflex. Noxious stimulation elicited decerebrate posture on the left and there was a paucity of movements on the right. The patient was taken up for emergency surgical decompression. Intraoperatively, the cerebellum was tense and the tumour was extending across the tentorium. Subtotal excision of the tumor was done. Postoperatively, sensorium of the patient continued to be poor. A tracheostomy was done on the third postoperative (PO) day. On the sixth PO day, the patient regained consciousness and from then on showed improvement. He was gradually weaned off the mechanical ventilation. At discharge on 37th PO day, the patient was conscious, obeying commands, and accepting nasogastric (NG) feeds with mobilisation on wheel chair.