Cerebral herniation as a complication of chest tube drainage of cerebrospinal fluid after injury to the spine

Background: Patients with concomitant injuries to the thorax and thecal sac requiring chest tube drainage are at risk for cerebral herniation caused by overdrainage of cerebrospinal fluid (CSF). Case Description: A 40-year-old man presented to the trauma service awake, alert, and oriented with an isolated gunshot wound to the midaxillary line through the tenth intercostal space and a complete spinal cord injury at T12. The patient was stabilized and intubated. A chest tube was placed, and he was transferred to the neurologic intensive care unit. The patient was found to be comatose with complete absence of brainstem reflexes 3 hours after admission. Results: Magnetic resonance imaging (MRI) and autopsy revealed diffuse cerebral edema, occlusion of the bilateral posterior cerebral arteries, and tonsillar herniation extending several centimeters below the foramen magnum, with petechial hemorrhages and absence of gliosis. Conclusions: To the authors' knowledge, this case represents the first report of cerebral herniation secondary to chest tube drainage of a CSF leak caused by traumatic injury to the thecal sac.