BACKGROUND: Lumbar puncture (LP) is a key diagnostic and therapeutic tool, yet concerns persist about its potential to induce brain herniation, especially in patients with elevated intracranial pressure (ICP). Despite ongoing debate, precise risk factors and pathophysiological mechanisms remain unclear. OBJECTIVE: This systematic review aims to examine the risk of cerebellar and paradoxical brain herniation following LP, evaluate the current evidence regarding its incidence, and discuss the implications for clinical practice as well as show the gaps in research. METHODS: Following PRISMA guidelines, a systematic literature review was conducted using the PubMed (MEDLINE) database. Studies from 1990 to 2024 focusing on bacterial meningitis, idiopathic intracranial hypertension, post-surgical states, and other conditions associated with elevated ICP were included. RESULTS: LP-related herniation was reported in diverse clinical settings, with cerebellar herniation primarily seen in bacterial meningitis and idiopathic intracranial hypertension. Herniation onset varied from minutes to days post-LP. While cranial CT is widely used for risk assessment, its predictive accuracy is debated. CONCLUSIONS: Although LP is relatively safe, herniation risk is highly context-dependent. Clinicians should integrate clinical, radiological, and pathophysiological factors in decision-making. Further research is needed to refine predictive models and establish evidence-based guidelines for high-risk patients.

Department of Neurosurgery 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Neurosurgery and Neurooncology 1st Faculty of Medicine Charles University and Military University Hospital Prague Czech Republic

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