Remote Cerebellar Hemorrhage Following Surgery for Supratentorial Lesions

Remote cerebellar hemorrhage after supratentorial craniotomy: illustrative cases

BACKGROUND

Remote cerebellar hemorrhage (RCH) is an extremely rare and potentially fatal complication after supratentorial craniotomy. However, the exact pathophysiological mechanism of RCH remains unclear, so clinicians often lack clinical experience in prevention, early diagnosis, and standardized treatment.

OBSERVATIONS

The authors retrospectively analyzed data of patients who underwent surgery for supratentorial lesions at their center between 2012 and 2021. They identified 4 patients who developed RCH among 4,075 patients who underwent supratentorial craniotomy. All 4 patients were male, with an average age of 57.5 years. One RCH occurred after tumor resection, and the other 3 occurred after aneurysm clipping. One patient was asymptomatic and received conservative treatment with a favorable outcome. The remaining 3 patients underwent lateral ventricular drainage and/or suboccipital decompression; 2 died, and 1 recovered well.

LESSONS

The authors believe that RCH should be considered as a multifactorial cause, and massive cerebrospinal fluid loss plays a key role in the development and progression of RCH. Asymptomatic RCH can be treated conservatively. However, in the case of conscious disturbance, hydrocephalus, and brain stem compression, surgery should be performed immediately. Early detection and individualized treatment would be helpful to avoid potentially fatal outcomes caused by RCH.

Intracranial hemorrhage following drainage of chronic subdural effusion and hematoma: A case report and review of the literature

Acute intracranial hemorrhage (AIH) after drainage of chronic subdural hematoma is a rare but serious complication. An 86-year-old man with bilateral frontotemporal subdural effusion, hematoma, and cerebral hernia was admitted to our department and treated with bilateral burr hole surgery and closed-system drainage under local anesthesia. After the operation, computed tomography (CT) showed AIH in the left temporal and occipital lobe, and then a series of head CT showed that the hematoma gradually increased day by day. This patient had a medical history of hypertension, diabetes, atrial fibrillation, and taking warfarin. He was treated conservatively, but had not recovered at discharge after 1 month. We reviewed the relevant literature and analyzed the operation opportunity, causes of cerebral hemorrhage, and preventive measures in similar patients. We suppose that the coagulation abnormality and rapid fluctuations of intracranial pressure were the main causes of development of AIH in our patient. Several possible reasons such as brain shift and impaired vascular autoregulation are also associated with postoperative AIH. We must be aware of this complication and keep some preventive measures in our mind.

Spectrum of remote site extradural hematomas following decompressive craniectomy: Does fracture always co-exist?

Background

Remote-site extradural hematomas (EDHs) after decompressive-surgeries for traumatic brain injury (TBI) are rarely encountered. Typically, they form contralateral to the injured side, with an overlying fracture. We present a subset which developed EDH immediately after decompressive-hemi-craniectomy for TBI, most without an evidence of fracture, and not limited to contralateral location.

Methods

Nine such patients were retrospectively identified. Plausible mechanisms, management issues and outcomes have been discussed.

Results

All nine patients were victims of severe-TBI. Six did not have any skull-fractures. Eight showed hemispheric-injuries while one had bifrontal-contusions. In hemispheric-injuries, midline-shift was at least 8 mm except one with midline-shift of 6 mm. The EDH was straddling the midline in 2 (bifrontal-1, bi-occipital-1), and juxtaposed to the previous craniectomy in 1, apart from a contralateral-bleed in 6; all, except one, needed evacuation. In most patients, venous-source of bleed was identified. All had improved from their preoperative Glasgow coma scale (GCS) at follow-up.

Conclusion

A fracture need not always co-exist in EDH following decompressive craniectomy. However, an extra-caution is suggested in its presence. Given the need for surgical-evacuation in most patients and an inability to assess immediate postoperative-GCS in severely head-injured, a routine postoperative-computed tomography is recommended to avoid overlooking such potentially treatable condition.

Subdural Hematoma Related to Dural Tear During Lumbar Spine Surgery: A Case Report and Review of the Literature

Subdural hematoma is a rare complication after lumbar spine surgeries. Most of the time, the reason for this complication is intracranial hypotension related to an unintended durotomy, and the main symptom is persistent orthostatic headache. The authors present the case of a-38-year-old woman who underwent lumbar discectomy. Three weeks after the surgery, she developed subdural hematoma related to dural tear during the procedure. Emergent hematoma evacuation with craniotomy and dural tear repair was performed simultaneously because of the herniation symptoms of the patient. Clinical findings, radiological assessments, and treatment modalities have been discussed in the presence of a literature review in this case report.

Risk factors of postoperative remote intracerebral hemorrhage after craniotomy for ruptured cerebral aneurysms

Objective

We aimed to identify the relation between perioperative cerebrospinal fluid (CSF) drain through lumbar drainage (LD) and development of postoperative (POP) remote intracerebral hemorrhage (rICH) in craniotomy to treat ruptured intracranial aneurysms.

Methods

We retrospectively reviewed consecutive patients who underwent craniotomy for ruptured cerebral aneurysms at the authors’ institution between 1998 and 2004. We subsequently compared the incidence and characteristics of POP rICH between the patients who had a perioperative LD and those who did not. All statistical analyses were conducted using the software package SPSS 19.0 (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant.

Results

We enrolled 688 patients, of which 80 patients (11.6%) received perioperative LD, and 608 did not. LD and non-LD groups were comparable because although clinical characteristics of the two groups were significantly different considering history of hypertension, timing of surgery, and closed system negative pressure suction drain (SD) placement, none of these three variables was an independent risk factor associated with POP rICH in multivariate analysis. POP rICH incidence was significantly higher in the LD goup (12.5%) than non-LD group (0.8%) (p=0.000) in univariate analysis. LD placement was the only independent risk factor associated with the development of rICH in multivariate logistic regression analysis.

Conclusions

POP rICH incidence was significantly higher in patients who were managed with perioperative LD than in those who did not. LD insertion in craniotomy for ruptured intracranial aneurysm, should be closely monitored to address the occurrence of POP rICH.