Brain stem herniation secondary to cerebrospinal fluid drainage in ruptured aneurysm surgery: a case report

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Table 2 Summary of the literature search on diagnosis and treatment for brain sag in SAH

References	No. of patients	Clinical manifestations	Brain image (CT or MRI)	Amount of CSF removed intraoperatively (cc)	Treatment	Permanent neurologic deficit
Samadani et al. (2003)	2	Drowsiness Cranial N. deficits	Epidural hematoma Effaced cisterns Brain stem infarction	50 cc, 63 cc	Epidural blood patch, Surgery^a	1^b
Komotar et al. (2005)	11	Decrement of GCS Pupillary asymmetry	Oblonged brain stem Effaced cisterns	Not documented	Trendelen-burg	2^c
Alaraj et al. (2011)	5	Decerebrate posture Pupillary change	Oblonged brainstem	30 cc	Trendelen-burg	1(dead)
Kawahara et al. (2013)	11	Anisocoria Mental status decline	Oblonged brainstem Effacement of basal cisterns	Not documented	Trendelen-burg	Not documented
Kim et al. (2016) (Present study)	1	Decreased mentality Pupillary asymmetry	Downward migration of splenium Oval shaped pons	50 cc	Trendelen-burg	0

^aSurgical evacuation was needed in one patient due to epidural hematoma with mass effect and midline shift. Another patient required epidural blood patch for persistent CSF leak
^bThe patient with brain stem infarction failed to respond to epidural blood patch
^cPatients with Hunt and Hess grade IV