Remote Cerebellar Hemorrhage after Lumbar Spinal Surgery

Abstract

Remote cerebellar hemorrhage (RCH) is rare but potentially lethal as a complication of spinal surgery. We recently experienced a case of RCH in a 61-year-old man who showed mental deterioration after lumbar spinal surgery. There was dural tearing with subsequent cerebrospinal fluid (CSF) loss during the surgery. Brain computed tomography scan revealed cerebellar hemorrhage, 3rd and 4th ventricular hemorrhage and pneumocephalus. He underwent suboccipital craniectomy and hematoma removal. The most important pathomechanism leading to RCH after spinal surgery has been known to be venous bleeding due to caudal sagging of cerebellum by rapid leak of large amount of CSF which seems to be related with this case. Dural repair and minimizing CSF loss after intraoperative dural tearing would be helpful to prevent postoperative RCH.

Immediate complications associated with high-flow cerebrospinal fluid egress during endoscopic endonasal skull base surgery

“…Authors have documented RCH occurring in conjunction with supratentorial surgery, spinal surgery, and simply with lumbar drainage. 8,9,16 Though the mechanism by which RCH occurs has not been demonstrated experimentally, most authors agree that it is attributable to venous infarction. The hypothesis holds that rapid loss of a large volume of CSF leads to caudal displacement of the cerebellum, which stretches draining veins to the point of occlusion, which then causes venous congestion and ultimately parenchymal hemorrhage.…”

“…The hypothesis holds that rapid loss of a large volume of CSF leads to caudal displacement of the cerebellum, which stretches draining veins to the point of occlusion, which then causes venous congestion and ultimately parenchymal hemorrhage. 8,9,16 These veins can also rupture and cause local subarachnoid hemorrhage, which is commonly seen in association with RCH. Case 2 provides a clear example of not only this potentially devastating complication but also TP, which was a concomitant but unrelated complication of CSF egress.…”

Remote intracranial parenchymal haematomas as complications of spinal surgery: presentation of three cases with minor or untypical symptoms

“…Since then, eight more cases of patients with cerebellar haematoma after spinal operations have been published [5 (2 cases), 7,8,12,14,20,21].…”

Intracranial hemorrhage following lumbar spine surgery

“…Cerebellar ''sag'' which is a result of excessive CSF leakage has been proposed to cause stretching and occlusion of the superior vermian veins. In patients with insufficient venous collaterals, this may cause venous infarction, subsequently leading to hemorrhagic transformation [2,[6][7][8][9][10][11][12][13][14][15] as occurred in our first and second cases. Another explanation is a rise in transmural venous pressure associated with CSF drainage and intracranial hypotension [2].…”

“…Another explanation is a rise in transmural venous pressure associated with CSF drainage and intracranial hypotension [2]. According to the experience with RCH after spinal surgery to date (30 cases), it appears that this type of hemorrhage can occur after any type of spinal surgery, in which large-volume CSF loss has occurred during or after surgery, regardless of body positioning [2,[6][7][8][9][10][11][12][13][14][15]. RCH should be suspected in any patient with unexplained deterioration of consciousness or with delayed emergence from anesthesia following spine surgery complicated by dural tear and CSF leak [2,[6][7][8][9][10][11][12][13][14][15].…”