• Takahide Haku, Yasushi Motoyama, Yoshiaki Takamura, Shuichi Yamada, Ichiro Nakagawa, Young-Su Park, and Hiroyuki Nakase.
• Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan.
• World Neurosurg. 2018 Sep 1; 117: 182-185.

BackgroundChronic subdural hematoma (CSDH) often occurs in association with cerebrospinal fluid (CSF) hypovolemia. Many cases with CSDH due to CSF hypovolemia and treated by burr hole surgery have been reported to present with paradoxical deterioration. However, the mechanisms and pathology of deterioration after surgery for CSDH due to CSF hypovolemia remain obscure.Case DescriptionWe report herein a 62-year-old man with gait disturbance due to subdural fluid collection (SDFC) who underwent burr hole irrigation and additional craniotomy, in which postoperative deterioration resulted from rapidly progressing central herniation with a large amount of air accumulation. Epidural blood patch with saline infusion in the thoracic spine finally resolved central herniation.ConclusionSDFC deteriorating after surgery has never been reported. SDFC has communication with CSF differing from mature CSDH composed of closed cavity surrounded by neomembrane. Under situations of CSF hypovolemia due to spinal dural tear, opening the cranium can prompt air replacement in the CSF space, which might represent a substantial risk for central herniation caused by a rapid loss of buoyancy force.Copyright © 2018 Elsevier Inc. All rights reserved.

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