Cerebellar hemorrhage after supratentorial surgery for treatment of epilepsy: report of three cases

Remote Cerebellar Haemorrhage: A Potential Iatrogenic Complication of Spinal Surgery

We report the case of a 51-year-old man with no significant past medical history, who underwent elective revision spinal surgery and subsequently developed intracranial hypotension, remote cerebellar haemorrhage (RCH), and mild hydrocephalus on the fourth postoperative day. Remote cerebellar haemorrhage is a known complication of supratentorial surgery. This iatrogenic phenomenon may also occur following spinal surgery, due to dural tearing and rapid cerebral spinal fluid (CSF) leakage, resulting in intracranial hypotension and cerebellar haemorrhage. This complication may result in severe permanent neurologic sequelae; hence, it is of pertinence to diagnose and manage it rapidly in order to optimise patient outcome.

Remote cerebellar hemorrhage after supratentorial procedures (part 1): a systematic review

A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which may rarely occurs as a complication of supratentorial procedures, and it shows a typical bleeding pattern defined "the zebra sign." However, its pathophysiology still remains unknown. We performed a comprehensive review collecting all cases of RCH after supratentorial craniotomies reported in literature in order to identify the most frequently associated procedures and the possible risk factors. We assessed percentages of incidence and 95 % confidence intervals of all demographic, neuroradiological, and clinical features of the patients. Univariate and multivariate analyses were used to evaluate their association with outcome. We included 49 articles reporting 209 patients with a mean age of 49.09 ± 17.07 years and a male/female ratio 130/77. A RCH was more frequently reported as a complication of supratentorial craniotomies for intracranial aneurysms, tumors debulking, and lobectomies. In the majority of cases, RCH occurrence was associated with impairment of consciousness, although some patients remained asymptomatic or showed only slight cerebellar signs. Coagulation disorders, perioperative cerebrospinal fluid drainage, hypertension, and seizures were the most frequently reported risk factors. Zebra sign was the most common bleeding pattern, being observed in about 65 % out of the cases, followed by parenchymal hematoma and mixed hemorrhage in similar percentages. A multivariate analysis showed that symptomatic onset and intake of antiplatelets/anticoagulants within a week from surgery were independent predictors of poor outcome. However, about 75 % out of patients showed a good outcome and a RCH often appeared as a benign and self-limiting condition, which usually did not require surgical treatment, but only prolonged clinical surveillance, unless in the event of the occurrence of complications.

Thoracic spinal subdural hematoma complicating anterior cervical discectomy and fusion: case report

A spinal subdural hematoma is a rare clinical entity with considerable consequences without prompt diagnosis and treatment. Throughout the literature, there are limited accounts of spinal subdural hematoma formation following spinal surgery. This report is the first to describe the formation of a spinal subdural hematoma in the thoracic spine following surgery at the cervical level. A 53-year-old woman developed significant paraparesis several hours after anterior cervical discectomy and fusion of C5–6. Expeditious return to operating room for anterior cervical revision decompression was performed, and the epidural hematoma was evacuated without difficulty. Postoperative imaging demonstrated a subdural hematoma confined to the thoracic level, and the patient was returned to the operating room for a third surgical procedure. Decompression of T1–3, with evacuation of the subdural hematoma was performed. Postprocedure, the patient’s sensory and motor deficits were restored, and, with rehabilitation, the patient gained functional mobility. Spinal subdural hematomas should be considered as a rare but potential complication of cervical discectomy and fusion. With early diagnosis and treatment, favorable outcomes may be achieved.

Remote Postoperative Epidural Hematoma after Brain Tumor Surgery

A postoperative epidural hematoma (EDH) is a serious and embarrassing complication, which usually occurs at the site of operation after intracranial surgery. However, remote EDH is relatively rare. We report three cases of remote EDH after brain tumor surgery. All three cases seemed to have different causes of remote postoperative EDH; however, all patients were managed promptly and showed excellent outcomes. Although the exact mechanism of remote postoperative EDH is unknown, surgeons should be cautious of the speed of lowering intracranial pressure and implement basic procedures to prevent this hazardous complication of brain tumor surgery.

Remote Supratentorial Hemorrhage following Supratentorial Craniotomy: A Case Report

Intracranial hemorrhage (ICH) in regions remote from the initial intracranial operation site is rare. The mechanism of ICH following cranial surgery remains unclear, although several theories have been proposed. Most of the reports describe cerebellar hemorrhages after supratentorial procedures or supratentorial hemorrhages after infratentorial procedures. Remote supratentorial hemorrhage (RSH) following supratentorial surgery is extremely rare. We report a case of postoperative RSH occurring away from the surgical site. A 62-year-old woman underwent a right occipital lobectomy to resect lung carcinoma metastases. The patient developed a postoperative consciousness disturbance, and a brain computed tomography (CT) scan revealed an ICH in the left frontal region. The patient underwent ICH evacuation, but remained severely disabled. It is necessary to be aware that this complication is possible after craniotomy.

Analysis of the risk factors for development of post-operative extradural hematoma after intracranial surgery

OBJECTIVE

Post-operative extradural hematoma (EDH) is a relatively common complication in patients undergoing intracranial operations. The risk factors associated with the occurrence of EDH are not well described in the literature. The objective of this study was to identify the risk factors and the incidence of post-operative EDH adjacent and regional to the craniotomy or the craniectomy site.

METHOD

This was a retrospective study of 24 (2.6% of total) patients who underwent extradural hematoma evacuation after primary intracranial supratentorial surgery between January 2005 and December 2011. During this period, 941 intracranial operations were performed. The control group (72 patients) was selected on the basis of having undergone the same pre-operative diagnosis and treatment within 2 months of the operations for the 24 hematoma patients. The Glasgow Coma Scale score and operation character (emergency or elective) of the hematoma and control group were individually matched to minimize pre-operative conditional bias. The ages of both groups were individually matched with similar ages within 10 years of each other to minimize age bias.

RESULT

Univariate analysis showed that the significant pre-operative and intra-operative factors associated with post-operative EDH were an intra-operative blood loss of greater than 800 mL (p=0.007), maximal craniotomy length of greater than or equal to 100 mm (p=0.001), and craniotomy area of greater than or equal to 71.53 cm2 (p=0.018). In multivariate analysis, intra-operative blood loss exceeding 800 mL (median of total patients) placed a patient at significantly increased risk for post-operative EDH.

CONCLUSION

The data did not examine established risk factors for post-operative hematoma, such as thrombocytopenia, anti-coagulant and anti-platelet therapy, and a history of heavy alcohol consumption and/or tobacco intake. Recognizing the limitations of the study, large intra-operative blood loss and wide craniotomy area are implicated with an increased risk of post-operative EDH after intracranial surgery.

Intracranial hemorrhage after spine surgery

OBJECT

The authors describe the largest case series of 8 patients with intracranial hemorrhage (ICH) after spinal surgery and identify associated pre-, intra-, and postoperative risk factors in relation to outcome.

METHODS

The authors retrospectively reviewed the cases of 8 patients treated over 16 years at a single institution and also reviewed the existing literature and collected demographic, treatment, and outcome information from 33 unique cases of remote ICH after spinal surgery.

RESULTS

The risk factors most correlated with ICH postoperatively were the presence of a CSF leak intraoperatively and the use of drains postoperatively with moderate hourly serosanguineous output in the early postoperative period.

CONCLUSIONS

Intracranial hemorrhage is a rare complication of spinal surgery that is associated with CSF leakage and use of drains postoperatively, with moderate serosanguinous output. These associations do not justify a complete avoidance of drains in patients with CSF leakage but may guide the treating physician to keep in mind drain output and timing of drain removal, while noting any changes in neurological examination status in the meantime. Additionally, continued and worsening neurological symptoms after spinal surgery may warrant cranial imaging to rule out intracranial hemorrhage, usually within the first 24 hours after surgery. The presence of cerebellar hemorrhage and hydrocephalus indicated a trend toward worse outcome.

Subdural and cerebellar hematomas which developed after spinal surgery: a case report and review of the literature

Cerebellar hemorrhage following a spinal surgery is extremely rare; however, considering the localization, it can cause major clinical manifestations. While it is considered that these types of bleedings occur secondary to a venous infarct, the pathogenesis is still unclear. A 57-year-old male patient who underwent a laminectomy by exposing T12-L5 and had pedicle screws placed for ankylosing spondylitis developed a CSF leak due to a 2 mm dural tear. A hemorrhage with parallel streaks on the left cerebellar hemisphere was seen in CT scan, and a thin subdural hematoma at right frontotemporal region was seen on cranial MRI, performed after the patient developed intense headache, nausea, vomiting, and stiff neck in the early postoperative period. In this paper, a case of cerebellar and subdural hematomas following a spinal surgery is discussed with its clinical and radiologic findings.

Multiple remote epidural hematomas following pineal gland tumor resection

In cases of pineal tumor combined with obstructive hydrocephalus, preoperative ventriculostomy or ventriculoperitoneal shunting is typically required prior to tumor resection. The objectives of preoperative ventriculostomy are gradual reduction of intracranial pressure and consequent preoperative brain protection. Here we report a case of pineal tumor resection with preoperative ventriculostomy that was complicated by multiple epidural hematomas. While postoperative intracranial hemorrhage may occur at any site, it is rare in those areas remote from the operative field. In the present case, multiple remote sequential epidural hematomas developed following resection of a pineal gland tumor. We also discuss the pathophysiologic mechanisms and provide a literature review.

Bilateral late remote cerebellar hemorrhage as a complication of a lumbo-peritoneal shunt applied after spinal arteriovenous malformation surgery

BACKGROUND/OBJECTIVE

Cerebellar hemorrhage is a very infrequent and unpredictable complication of spinal surgery. To the best of our knowledge, cerebellar hemorrhage resulting from the insertion of a lumbo-peritoneal shunt through which cerebrospinal fluid (CSF) is slowly drained has not been documented to date.

METHODS

Case report.

RESULTS

A 47-year-old woman presented with lower extremity weakness. Spinal arteriovenous malformation was diagnosed, and she underwent surgery. Her neurologic status improved; however, CSF collected subcutaneously as a cyst and leaked 21 days after surgery. The patient underwent urgent surgery during which the dural defect was repaired and a lumbo-peritoneal catheter was put in place to treat the CSF leakage. The lumbo-peritoneal drainage system was removed when bilateral cerebellar hemorrhage was seen 12 days later. Physical therapy was stopped, and conservative treatment was initiated consisting of bed rest, analgesics, sedatives, and careful monitoring of blood pressure. The patient's headache gradually resolved; physical therapy was restarted to rehabilitate this patient with paraparesis.

CONCLUSIONS

Remote cerebellar hemorrhage seems to be life threatening and entails significant morbidity. Cerebellar symptoms, and even a late sudden headache after spinal surgery, may be signs of remote cerebellar hemorrhage, which is a rare complication.

Pseudohypoxic brain swelling after elective clipping of an unruptured anterior communicating artery aneurysm

A case of pseudohypoxic brain swelling, a newly defined entity, is described. The patient experienced generalized seizures and did not awake initially after a seemingly uneventful elective craniotomy for clipping of an unruptured anterior communicating artery aneurysm. Neuroimaging findings demonstrated diffuse brain swelling, especially in the bilateral basal ganglia and thalami. The rarity of this postoperative complication is addressed and the pathogenesis discussed.

Remote cerebellar hemorrhage complicated after supratentorial surgery: retrospective study with review of articles

OBJECTIVE

Remote cerebellar hemorrhage (RCH) is one of the rare complications occurring after supratentorial surgery, and its pathomechanism is poorly understood. We report 10 cases of RCH from our institution and review 154 cases from a database in order to delineate incidence, common presentation, risk factors, and outcomes of this complication. In addition, the means of prevention are discussed.

METHODS

We reviewed the medical records of 10 patients who experienced RCH after undergoing supratentorial surgery at our institution between 2001 and 2008. A database search in Medline revealed 154 cases of RCH in the English literature. Characteristic features were analyzed and compared.

RESULTS

There were 10 cases of RCH among 3307 supratentorial surgery cases, indicating a 0.3% incidence. All patients had characteristic imaging features of RCH, namely a streaky bleeding pattern in the superior folia of the cerebellum. Seven patients had a history of preoperative hypertension. Four cases were related to cerebral aneurysms, and other four developed after the removal of brain tumors. Cerebrospinal fluid (CSF) drainage apparatuses were installed postoperatively in all cases. Outcomes according to modified Rankin scale (mRS) were good in 7 patients, with 1 fatal case.

CONCLUSION

RCH is a rare complication after supratentorial surgery, and the exact etiology still remains uncertain. Hypertension and perioperative loss of CSF seem positively correlated with RCH, but no single risk factor is totally responsible. Patients with RCH should be closely observed to improve their prognosis.

Remote cerebellar hemorrhage following resection of a supratentorial tumor: a case report

Remote cerebellar hemorrhage after supratentorial surgery is rare, ranging between 0.08% and 0.29% in adults and children. However, it is extremely rare in children. This phenomenon underlying mechanisms remain obscure. A 14-year-old male child patient had a history of right focal seizures and underwent craniotomy for a left frontal mass (Dysembryoplastic Neuroepithelial Tumor). First hours post recovery period, the patient was somnolent and had right hemiparesis. Postoperative Computer Tomography and magnetic resonance imaging findings revealed that the patient had developed remote cerebellar hemorrhage. He was treated conservatively, and was free of neurological deficits.Although dehydration and the displacement of the cerebellum are associated with this phenomenon after supratentorial surgery, the identification of the exact etiological factors remains elusive. It is advisable for case givers to be aware of the high potential risk of morbidity and mortality of this entity. Preoperative attention to prevent cerebrospinal fluid overflow leakage and exaggerated dehydration of the patient may prevent remote cerebellar hemorrhages.

Remote cerebellar hemorrhage after supratentorial unruptured aneurysmal surgery: report of three cases

We report three cases of remote cerebellar hemorrhage that developed after supratentorial unruptured aneurysmal surgery. In all cases, digital subtraction angiography was performed before each operation in order to rule out other vascular abnormalities, especially around the operative field or the posterior circulation. In addition, all patients were screened for any previous history of bleeding tendencies or other related medical disorders. Each patient underwent clipping surgery via the pterional approach. Remote cerebellar hemorrhage was identified on post-operative computed tomographic scans. In all cases, there was no evidence of significant associated long-term morbidity. A consideration of the possible pathophysiologic mechanisms underlying these post-operative remote cerebellar hemorrhages and suggested strategies for avoiding such complications are discussed.

Lumbar subdural haematoma after temporomesial resection in epilepsy patients-report of two cases and review of the literature

We present two cases of lumbar subdural haematoma, both occurring after an uneventful temporomesial focus resection in patients suffering from medically intractable epilepsy. Initial symptom was back pain and sciatica 4 days and 13 days postoperatively, but no neurological deficits were observed. The diagnosis was confirmed by MRI. No risk factor could be identified. The pain responded well to conservative treatment and the haematomas resolved without neurological sequelae. A review of the literature reveals that the characteristics of spinal subdural haematoma following craniotomy are very similar. Six out of 12 reported cases occurred in temporal epilepsy surgery. All had a benign course and did not require an operative procedure. Back pain after epilepsy surgery may be caused by an intraspinal haematoma and should be investigated by MRI.

Lesionectomy in epileptogenic gangliogliomas: seizure outcome and surgical results

We retrospectively analysed seizure outcome and surgical results in a series of 21 patients with ganglioglioma treated with lesionectomy. The 21 patients (13 males, eight females) had a history of epilepsy longer than 1 year and post-operative follow up of at least 1 year. Information on the duration of the seizures, type and frequency was retrieved from medical records. In all patients, surgery was limited to the tumour. The interval between onset of seizures and surgery ranged from 1 to 35 years (mean 11). Patient age ranged from 6 to 61 years (mean 27.5). Fifteen patients (71.4%) had complex partial seizures and six had simple partial seizures. Secondary generalisation was present in 10 patients (47.6%). Seizure frequency varied from several per day to one per month. Sixteen tumours were temporal (76.1%; 11 temporo-mesial, five temporo-lateral), and five were extratemporal (23.8%). The mean follow-up period was 5.4 years (range: 1.25-10 years). No tumour progression was observed. No patient died during surgery or the post-operative course. Fourteen patients (66.6%) were Engel class I (five temporo-mesial, five temporo-lateral, four extratemporal) and seven (33.3%) were Engel class II. Post-operative complications were observed in six patients (28.6%), two of whom had cerebellar haemorrhage, possibly due to increased transmural venous pressure. In our patients with temporal neocortical and extratemporal ganglioglioma, lesionectomy allowed good seizure control. The unsatisfactory outcome for mesiotemporal gangliogliomas might indicate the need for extensive neurophysiological presurgical evaluation in order to perform tailored surgery. To avoid cerebellar haemorrhage, attention should be paid to those factors involved in transmural venous pressure increases.

Remote cerebellar hemorrhage: A review

Remote cerebellar hemorrhage remains a complication rarely occurring after supratentorial surgery (<5%) and presumably even less frequent after spinal surgery. Although the pathomechanisms leading to RCH with its typical bleeding pattern are still not definitely understood, intra- or even more likely postoperative loss of larger volumes of CSF seem to be related to this complication. Prognosis significantly depends on severity of hemorrhage and patient age. Outcome in more than 50% of all cases is good with only mild remaining neurological symptoms or complete recovery, while death occurs in approximately 10-15%. Close monitoring of patients undergoing surgery that involves the risk of draining large volumes of CSF is mandatory and patients with postoperative drainage of larger amounts of fluid acquire increased attentiveness. Early detection and correct interpretation of the typical bleeding pattern might help to avoid further aggravation of symptoms. This review will address incidence, typical appearance and pathophysiological considerations, as well as risk factors, treatment options, and outcome related with RCH.

Cerebellar haemorrhage following supratentorial craniotomy

Distant cerebellar haemorrhage is a rare complication occurring in approximately 0.3-0.6% of all supratentorial craniotomy. A Medline and Pubmed search revealed only 98 cases in the English literature. We report three cases from our institution. An overall review of these 101 cases demonstrated that this complication commonly presented early in the postoperative course as decreased level of consciousness following aneurysm repair surgery or lobectomy for epilepsy. Asymptomatic presentation due to small haemorrhage was not uncommon. A transtentorial pressure gradient set up by excessive CSF loss is generally held responsible for disrupting the cerebellar venous blood flow and consequently leading to venous haemorrhage. Perioperative hypertension may also play a role. The outcome of patients who survived the complications was generally good, though not infrequently fatality resulted from the mass effect of extensive cerebellar haemorrhage demanded vigilance in its management.

Cerebellar hemorrhage after supratentorial craniotomy

BACKGROUND

Cerebellar hemorrhage following supratentorial craniotomy is a very seldom described but serious complication. The present study evaluates the significance of presurgical and surgical factors that may predispose patients to these bleeding episodes.

METHODS

The data of 52 cases of cerebellar hemorrhage following supratentorial craniotomy, 9 from our records and 43 from the literature, were analyzed with regard to various variables.

RESULTS

The findings suggest that this clinical picture is unrelated to age, previous arterial hypertension, inherent or induced coagulopathies, type of primary underlying lesion, intraoperative positioning of the patient, type of anesthesia, or intracranial hypotension and its sequels. It entails significant morbidity, with one third of the patients left with cerebellar dysfunction or in a dependent state, and carries a mortality of about 25%.

CONCLUSION

Not one single presurgical or surgical factor can reliably predict the occurrence of cerebellar hemorrhage after supratentorial craniotomy, and the etiology of this entity still remains unclear. The most important keys to minimize the hazardous sequelae are to be aware of this potential complication and to diagnose it early.