Fatal remote cerebellar hemorrhage after supratentorial unruptured aneurysm surgery in patient with previous cerebellar infarction: A case report

Surgical Treatment of Congenital Kyphosis in Children: Report of a Rare Complication of Remote Cerebellar Haemorrhage

Congenital deformities of the spine lead to an imbalance in the longitudinal growth of the spine. These growth abnormalities may lead to three main patterns of deformity: scoliosis (the most common), kyphosis or lordosis (the least common). Despite the recent improvements in imaging and the routine use of neuromonitoring in the surgical treatment of congenital kyphosis, this surgery may be associated with a high rate of complications such as neurologic deficit, pulmonary thromboembolic events, infection, deep vein thrombosis, implant failure, and dural injury. In this paper, we report a rare yet devastating complication to raise awareness about patients who have unexpected neurological deterioration after spinal surgery. Early recognition of remote cerebellar haemorrhage (RCH) symptoms is crucial since rapid diagnosis and management lead to a favourable outcome for this potentially life-threatening complication. To our knowledge, this is the first reported case in children.

Remote Cerebellar Hemorrhage Associated With Intra-Operative Cerebrospinal Fluid Leak: A Report of Two Rare Case Presentations and Review of the Literature

Remote cerebellar hemorrhage (RCH) is a rare complication following cranial or spinal neurosurgical procedures. Traditionally, RCH has been associated with frontal or frontotemporal craniotomy with supine patient positioning. Though the exact etiology is unknown, theories have described patient positioning and excessive cerebrospinal fluid (CSF) drainage intra-operatively as contributing factors to cerebellar displacement (cerebellar sag), obstruction of venous flow, and pathogenesis of RCH. 

We report two cases of RCH following a prone, suboccipital craniotomy-C1 laminectomy and a temporal burr hole evacuation of a subdural hygroma. In each case, a large volume of CSF was rapidly evacuated intra-operatively. To the best of our knowledge, both instances represent relatively rare settings for RCH. Additionally, we conducted a comprehensive literature review of PubMed, EMBASE, and Web of Science for all cases of RCH in which peri-operative CSF leakage was explicitly detailed.

Although RCH is thought to be a rare complication of frontotemporal and frontal craniotomies, this case report signifies that RCH may occur in the setting of sub-occipital craniotomy or even after minimally invasive burr hole procedures. For these procedures, careful symptomatic monitoring and follow-up imaging remain essential in diagnosis. Controlled CSF drainage may be useful in mediating dramatic alterations in intracranial pressure (ICP) and cerebellar sag contributing to RCH.

Remote Cerebellar Hemorrhage Following Surgery for Supratentorial Lesions

BACKGROUND

Remote cerebellar hemorrhage (RCH) after intracranial surgery is a rare complication. Cerebellar hemorrhage is the most commonly described remote site hemorrhage after surgery for supratentorial pathologies. Although this is a rare complication 0.04% to 0.8%, it can be devastating in terms of patient outcome. There are various hypotheses to explain the occurrence of RCH. We report 6 cases of RCH after surgery for supratentorial lesions, discuss the pathophysiology, and review the pertinent literature.

METHODS

We retrospectively analyzed data of patients who underwent surgery for supratentorial lesions at our center between 2015 and 2017. We identified 6 patients who developed RCH among 1200 patients who underwent surgery and reviewed the demographic data, diagnosis, surgical procedure, and final outcome.

RESULTS

A total of 1200 patients underwent surgery for supratentorial pathologies between 2015 and 2017. Six patients developed RCH (incidence, 0.5%); 5 were male and 1 was female, with a mean age of 46.4 years. One patient underwent suboccipital decompression for RCH; the rest 5 were managed with close observation and serial imaging. The Glasgow outcome scale (GOS) of 5 was observed in 4 patients, GOS of 4 in 1 patient at discharge, and GOS of 1 in 1 patient who succumbed to severe pulmonary infection after surgery.

CONCLUSIONS

RCH is a rare complication but can lead to catastrophic results. Loss of large volumes of cerebrospinal fluid or sudden alteration in intracranial pressure due to removal of a mass lesion is the likely etiology. Although majority of cases may be managed conservatively, in a subset of cases with neurologic deterioration, surgery may be required as a life-saving procedure.