Treatment of intractable paradoxical herniation by invasive mechanical ventilation with increased positive end-expiratory pressure: a case report.

Objective: Paradoxical herniation (PH) is a rare but potentially life-threatening complication after decompressive craniectomy. The core treatment strategy for PH focuses on increasing intracranial pressure. Here, we present the treatment course of intractable PH in a 59-year-old patient with a traumatic acute subdural hematoma.

Methods: The patient underwent two operations to evacuate intracranial hematomas followed by decompressive craniectomy within 48 h. Intractable PH was induced by persistent cerebrospinal fluid leakage due to multiple lumbar punctures. The condition was managed with conventional interventions, such as a supine position, intravenous fluid infusion, and multiple intrathecal saline injections, which have been proven to be inefficient. Owing to his unconsciousness and concurrent severe pneumonia, the patient underwent invasive mechanical ventilation with increased positive end-expiratory pressure (PEEP) to optimize oxygen delivery. PEEP was set at 10 cmH₂O with the intention of facilitating alveolar recruitment.

Results: Increased PEEP unexpectedly played a role in elevating intracranial pressure and, as a result, led to the complete resolution of PH. The patient gradually recovered and resumed his daily activities.

Conclusions: Applying invasive mechanical ventilation with increased PEEP for treating intractable PH can yield a favorable outcome. It represents a novel approach to dealing with such a rare complication.