Dr. Alisha Brown and Dr. Patrick Bender published a case report “Head of the Bed Down –Paradoxical Management for Paradoxical Herniation” in CPC Emergency Medicine. They describe a case of paradoxical herniation following lumbar puncture in a patient with previous hemicraniectomy. The symptomatology was similar to cerebral herniation from intracranial hypertension and included lethargy, bradycardia, headache, and compression of brain structures on non-contrast head computed tomography. However, contrary to treatment modalities for intracranial hypertension, management strategy aims to reverse intracerebral hypotension.
Treatment for paradoxical herniation involves increasing intracranial pressure using fluid resuscitation and Trendelenburg positioning. In the intensive care unit this patient received an epidural blood patch and hydration with resolution of his symptoms.