Remote cerebellar hemorrhage after lumbar spinal surgery

Abstract

Remote cerebellar hemorrhage (RCH) is a rare complication after supratentorial or spinal surgery. RCH is poorly known and hence probably underdiagnosed. Diminished consciousness and headache are the most common clinical features. Computed tomography and magnetic resonance reveal a characteristic pattern of linear bleeding between the cerebellar folia. The pathophysiological mechanism is disputed but is probably venous bleeding secondary to significant intraoperative or postoperative loss of cerebrospinal fluid. Multiple risk factors have been described, but postsurgical negative pressure drainage of cerebrospinal fluid is the only clearly predisposing factor. We present a case of RCH after spinal surgery with a literature review.

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].…”

“…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]. The clinical presentation ranges from transient cerebellar and brainstem dysfunction to large hematoma causing obstructive hydrocephalus [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]. The clinical presentation ranges from transient cerebellar and brainstem dysfunction to large hematoma causing obstructive hydrocephalus [2,[6][7][8][9][10][11][12][13][14][15]. The presence of the zebra sign, bilateral cerebellar involvement, and documented CSF hypotension can help define the diagnosis and avoid unnecessary workup [6,12,13].…”

“…Most cases with RCH can be treated conservatively with immediate removal of subfascial drain, complete bed rest, and Trendelenburg position and external ventricular drainage, but in some cases surgical removal of hematoma or re-exploration of the surgical site may be needed [2,[6][7][8][9][10][11][12][13][14][15]. EDH should be treated with hematoma evacuation [5].…”