Abstracts

Rationale: Brain sagging is a rare complication after craniotomy and clipping of a ruptured aneurysm, with reported rates of up to 8%. Real time changes in EEG abnormalities in patients with intracranial hypotension associated with positional changes have been only infrequently described and may be mistaken for more concerning rhythmic or periodic electrographic patterns. As a result, there may be a delay in the diagnosis and treatment of this potentially life threatening complication. Methods: Case report. Results: We present a case of intracranial hypotension where EEG changes were noted during active sagging of the brain and resolved with supine position. The patient is a 48 year old female who presented with the worst headache of her life and was found to have a subarachnoid hemorrhage secondary to right middle cerebral aneurysm. She was taken to the OR for a right frontotemporal craniotomy with clipping of the aneurysm. A lumbar drain was placed during the procedure to reduce intra-operative intracranial pressure. On Post-operative day 2, the patient appeared lethargic and complained of headache. CT head and basic labs were unremarkable, and an EEG was ordered. During upright seating, cEEG showed greatly increased highly rhythmic generalized slow wave activity that correlated clinically with decline in mentation. When placed in the supine position, the EEG changes resolved and the patient regained normal neurologic function. Conclusions: Brain sagging can be diagnosed using simple maneuvers such as supine positioning. This case report describes changes seen in cEEG monitoring that accompany these maneuvers that can provide further evidence for the diagnosis of brain sagging. Thus, cEEG monitoring may have a role in the early detection and treatment of brain sagging. It is the recommendation of the authors that positional changes be taken into consideration when evaluating concerning electrographic patterns in post craniotomy EEGs. Funding: none