# Paradoxical Brain Herniation: An Unexpected Diagnosis

## TL;DR

This paper presents a rare case of paradoxical brain herniation occurring after a meningioma surgery, highlighting the importance of recognizing uncommon neurosurgical complications.

## Contribution

The novelty lies in the detailed documentation of a rare complication following a meningioma excision and lumbar drain use.

## Key findings

- A patient developed paradoxical brain herniation after meningioma surgery and lumbar drain placement.
- Neurological worsening was reversed by increasing intracranial pressure and subsequent cranioplasty.
- The case underscores the need for heightened clinical suspicion of rare post-operative complications.

## Abstract

Paradoxical herniation is a dreadful neurosurgical complication often underdiagnosed, which typically becomes evident over the course of weeks to months after the initial intervention. Here we present a unique case with manifestations in the post-operative period. A patient initially referred to neurosurgery for a meningioma underwent an uneventful surgical excision, followed by the transient placement of a lumbar drain for 48 hours. On the first post-operative day, the patient exhibited progressively altered neurological status, with corresponding imaging revealing a transfalcine herniation, necessitating emergent decompressive craniectomy. Despite the medical and surgical interventions, there were continuous signs of neurological and imaging worsening, with increase in herniation, which led to the diagnosis suspicion of a paradoxical brain herniation. Consequently, a rapid reversal of neurological deficits was observed after applying maneuvers to augment the intracranial pressure, followed by cranioplasty. This case illustrates the utmost importance of clinical suspicion for the uncommon complications of neurointerventions.