Skip to main content

Advertisement

SpringerLink
Log in

Remote cerebellar hemorrhage after spinal procedures (part 2): a systematic review

  • Review
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which can be rarely observed as a complication of spine surgery. As well as for RCH reported after supratentorial procedures, it shows a characteristic bleeding pattern defined “zebra sign”. Nowadays, RCH pathophysiology still remains unknown. We performed a comprehensive review, collecting all cases of RCH after spine surgery reported in literature in order to identify the procedures most frequently associated with RCH and the possible risk factors. We assessed percentages of incidence and 95 % confidence interval of all demographic, neuroradiological, and clinical features. Univariate and multivariate analyses were used to evaluate their association with outcome. We included 44 articles reporting 57 patients with mean age of 57.6 ± 13.9 years and a male/female ratio of 23/34. A RCH was more frequently reported as a complication of decompressive procedures for spinal canal stenosis, particularly when associated with instrumented fusion, followed by spinal tumor debulking and disc herniation removal. In the majority of cases, RCH occurrence was characterized by progressive impairment of consciousness, whereas some patients complained non-specific symptoms. Coagulation disorders, hypertension, and placement of postoperative subfascial drainages were the most frequently reported risk factors. The occurrence of intraoperative dural lesions was described in about 93 % of patients. Zebra sign was the most common bleeding pattern (about 43 % of cases) followed by parenchymal hematoma (37.5 %) and mixed hemorrhage (about 20 %). Impairment of consciousness at clinical onset and intake of anticoagulants/antiplatelets appeared associated with poor outcome at univariate analysis. However, more than 75 % 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 of the occurrence of complications.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Baeesa SS (2012) Remote cerebellar hemorrhage in neurosurgery. Neurosciences (Riyadh) 17:305–308

    Google Scholar 

  2. Brockmann MA, Groden C (2006) Remote cerebellar hemorrhage: a review. Cerebellum 5:64–68

    Article  PubMed  Google Scholar 

  3. Chadduck WM (1981) Cerebellar hemorrhage complicating cervical laminectomy. Neurosurgery 9:185–189

    Article  CAS  PubMed  Google Scholar 

  4. Andrews RT, Koci TM (1995) Cerebellar herniation and infarction as a complication of an occult postoperative lumbar dural defect. AJNR Am J Neuroradiol 16:1312–1315

    CAS  PubMed  Google Scholar 

  5. Bowers CA, Taussky P, Duhon BS, Schmidt MH (2011) Multiple supra- and infratentorial intraparenchymal hemorrhages presenting with seizure after massive sacral cerebrospinal fluid drainage. Spine (Phila Pa 1976) 36:E288–E291

    Article  Google Scholar 

  6. Brockmann MA, Nowak G, Reusche E, Russlies M, Petersen D (2005) Zebra sign: cerebellar bleeding pattern characteristic of cerebrospinal fluid loss. Case report. J Neurosurg 102:1159–1162

    Article  PubMed  Google Scholar 

  7. Calisaneller T, Yilmaz C, Ozger O, Caner H, Altinors N (2007) Remote cerebellar haemorrhage after spinal surgery. Can J Neurol Sci 34:483–484

    Article  PubMed  Google Scholar 

  8. Cavanilles-Walker JM, Tomasi SO, Sgier F, Kröber M (2013) Remote cerebellar haemorrhage after lumbar spine surgery: case report. Arch Orthop Trauma Surg 133:1645–1648

    Article  CAS  PubMed  Google Scholar 

  9. Cevik B, Kirbas I, Cakir B, Akin K, Teksam M (2009) Remote cerebellar hemorrhage after lumbar spinal surgery. Eur J Radiol 70:7–9

    Article  PubMed  Google Scholar 

  10. Chalela JA, Monroe T, Kelley M, Auler M, Bryant T, Vandergrift A et al (2006) Cerebellar hemorrhage caused by remote neurological surgery. Neurocrit Care 5:30–34

    Article  PubMed  Google Scholar 

  11. Chauvet D, Silhouette B, Engrand N, Pradier F, Piotin M, Lot G (2012) Multiple Spinal Hemangioblastomas Complicated with Postoperative Remote Cerebellar Hemorrhage: Review of the Literature of Two Rare Entities. World Neurosurg

  12. Cornips EM, Staals J, Stavast A, Rijkers K, van Oostenbrugge RJ (2007) Fatal cerebral and cerebellar hemorrhagic infarction after thoracoscopic microdiscectomy. Case report. J Neurosurg Spine 6:276–279

    Article  PubMed  Google Scholar 

  13. Elmaci I, Ain MC, Wright MJ, Lee RR, Sheppard JM, Rigamonti D et al (2000) Perioperative intracranial hemorrhage in achondroplasia: a case report. J Neurosurg Anesthesiol 12:217–220

    Article  CAS  PubMed  Google Scholar 

  14. Enel D, Blamoutier A, Bacon P, Gentili ME (2009) Spine surgery associated with fatal cerebellar haemorrhage. Eur J Anaesthesiol 26:891–892

    Article  PubMed  Google Scholar 

  15. Farag E, Abdou A, Riad I, Borsellino SR, Schubert A (2005) Cerebellar hemorrhage caused by cerebrospinal fluid leak after spine surgery. Anesth Analg 100:545–546

    Article  CAS  PubMed  Google Scholar 

  16. Fernandez-Jara J, Jorge-Blanco A, Carro-Martinez AI, Ferreiro-Argüelles C, Fernandez-Gallardo JM, Romero-Coronado J (2011) Remote cerebellar hemorrhage after lumbar spinal surgery. Emerg Radiol 18:177–180

    Article  PubMed  Google Scholar 

  17. Friedman JA, Piepgras DG (2002) Remote cerebellar hemorrhage. J Neurosurg 97:498–499

    PubMed  Google Scholar 

  18. Gul S, Kalayci M, Acikgoz B (2010) A rare complication of spinal surgery: cerebellar hemorrhage. Turk Neurosurg 20:413–417

    PubMed  Google Scholar 

  19. Hashidate H, Kamimura M, Nakagawa H, Takahara K, Uchiyama S, Kato H (2008) Cerebellar hemorrhage after spine surgery. J Orthop Sci 13:150–154

    Article  PubMed  Google Scholar 

  20. Hempelmann RG, Mater E (2012) Remote intracranial parenchymal haematomas as complications of spinal surgery: presentation of three cases with minor or untypical symptoms. Eur Spine J 21:S564–S568

    Article  PubMed  Google Scholar 

  21. Huang PH, Wu JC, Cheng H, Shih YH, Huang WC (2013) Remote cerebellar hemorrhage after cervical spinal surgery. J Chin Med Assoc 76:593–598

    Article  PubMed  Google Scholar 

  22. Kaloostian PE, Kim JE, Bydon A, Sciubba DM, Wolinsky JP, Gokaslan ZL et al (2013) Intracranial hemorrhage after spine surgery. J Neurosurg Spine 19:370–380

    Article  PubMed  Google Scholar 

  23. Karaeminogullari O, Atalay B, Sahin O, Ozalay M, Demirors H, Tuncay C et al (2005) Remote cerebellar hemorrhage after a spinal surgery complicated by dural tear: case report and literature review. Neurosurgery 57:E215

    PubMed  Google Scholar 

  24. Khalatbari MR, Khalatbari I, Moharamzad Y (2012) Intracranial hemorrhage following lumbar spine surgery. Eur Spine J 21:2091–2096

    Article  PubMed  PubMed Central  Google Scholar 

  25. Khong P, Jerry Day M (2009) Spontaneous cerebellar haemorrhage following lumbar fusion. J Clin Neurosci 16:1673–1675

    Article  PubMed  Google Scholar 

  26. Konya D, Ozgen S, Pamir MN (2006) Cerebellar hemorrhage after spinal surgery: case report and review of the literature. Eur Spine J 15:95–99

    Article  PubMed  Google Scholar 

  27. Ladehoff M, Zachow D, Koch C, Nowak G, Echelmeyer A, Arnold H et al (2005) Cerebellar haemorrhage and tension pneumocephalus after resection of a Pancoast tumour. Acta Neurochir (Wien) 147:561–564

    Article  CAS  Google Scholar 

  28. Lee HY, Kim SH, So KY (2012) Seizure and delayed emergence from anesthesia resulting from remote cerebellar hemorrhage after lumbar spine surgery-a case report-. Korean J Anesthesiol 63:270–273

    Article  PubMed  PubMed Central  Google Scholar 

  29. Lehmann P, Saliou G (2011) Remote cerebellar haemorrhage. Eur J Radiol Extra 77:e29–e33

    Article  Google Scholar 

  30. Mikawa Y, Watanabe R, Hino Y, Ishii R, Hirano K (1994) Cerebellar hemorrhage complicating cervical durotomy and revision C1-C2 fusion. Spine (Phila Pa 1976) 19:1169–1171

    Article  CAS  Google Scholar 

  31. Morandi X, Riffaud L, Carsin-Nicol B, Guegan Y (2001) Intracerebral hemorrhage complicating cervical "hourglass" schwannoma removal. Case report. J Neurosurg 94:150–153

    CAS  PubMed  Google Scholar 

  32. Morofuji Y, Tsunoda K, Takeshita T, Hayashi K, Kitagawa N, Suyama K et al (2009) Remote cerebellar hemorrhage following thoracic spinal surgery. Neurol Med Chir (Tokyo) 49:117–119

    Article  Google Scholar 

  33. Nakazawa K, Yamamoto M, Murai K, Ishikawa S, Uchida T, Makita K (2005) Delayed emergence from anesthesia resulting from cerebellar hemorrhage during cervical spine surgery. Anesth Analg 100:1470–1471

    Article  PubMed  Google Scholar 

  34. Nam TK, Park SW, Min BK, Hwang SN (2009) Remote cerebellar hemorrhage after lumbar spinal surgery. J Korean Neurosurg Soc 46:501–504

    Article  PubMed  PubMed Central  Google Scholar 

  35. Ozturk E, Kantarci M, Karaman K, Basekim CC, Kizilkaya E (2006) Diffuse pneumocephalus associated with infratentorial and supratentorial hemorrhages as a complication of spinal surgery. Acta Radiol 47:497–500

    Article  CAS  PubMed  Google Scholar 

  36. Pallud J, Belaïd H, Aldea S (2009) Successful management of a life threatening cerebellar haemorrhage following spine surgery-a case report. Asian Spine J 3:32–34

    Article  PubMed  PubMed Central  Google Scholar 

  37. Sakaura H, Hosono N, Mukai Y, Ishii T, Yoshikawa H (2006) Multiple cerebellar hemorrhagic infarctions following surgery for a huge atlantoaxial neurinoma. Spine J 6:86–89

    Article  PubMed  Google Scholar 

  38. Sasani M, Ozer AF, Oktenoglu T, Karaarslan E, Sasani H, Kaner T (2009) Remote cerebellar hemorrhage following resection of a supratentorial tumor: a case report. Cases J 2:7299

    Article  PubMed  PubMed Central  Google Scholar 

  39. Satake K, Matsuyama Y, Iwata H, Sato K, Kawakami N (2000) Cerebellar haemorrhage complicating resection of a cervical intramedullary tumour. Spinal Cord 38:504

    Article  CAS  PubMed  Google Scholar 

  40. Takahashi Y, Nishida K, Ogawa K, Yasuhara T, Kumamoto S, Niimura T et al (2012) Multiple intracranial hemorrhages after cervical spinal surgery. Neurol Med Chir (Tokyo) 52:643–645

    Article  Google Scholar 

  41. Thomas G, Jayaram H, Cudlip S, Powell M (2002) Supratentorial and infratentorial intraparenchymal hemorrhage secondary to intracranial CSF hypotension following spinal surgery. Spine (Phila Pa 1976) 27:E410–E412

    Article  Google Scholar 

  42. Ulivieri S, Neri L, Oliveri G (2009) Remote cerebellar haematoma after lumbar disc surgery. Case report. Ann Ital Chir 80:219–220

    PubMed  Google Scholar 

  43. Yang KH, Han JU, Jung JK, Lee DI, Hwang SI, Lim HK (2011) Cerebellar hemorrhage after spine fixation misdiagnosed as a complication of narcotics use-a case report. Korean J Anesthesiol 60:54–56

    Article  PubMed  PubMed Central  Google Scholar 

  44. Yoo JC, Choi JJ, Lee DW, Lee S (2013) Remote cerebellar hemorrhage after intradural disc surgery. J Korean Neurosurg Soc 53:118–120

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. You SH, Son KR, Lee NJ, Suh JK (2012) Remote cerebral and cerebellar hemorrhage after massive cerebrospinal fluid leakage. J Korean Neurosurg Soc 51:240–243

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Sources of funding

The authors did not receive any funding in conjunction with the generation of this manuscript.

Author information

Authors and Affiliations

  1. Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy

    Carmelo Lucio Sturiale, Marta Rossetto, Mario Ermani, Valentina Baro, Francesco Volpin, Laura Milanese, Luca Denaro & Domenico d’Avella

Authors
  1. Carmelo Lucio Sturiale
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marta Rossetto
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mario Ermani
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Valentina Baro
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Francesco Volpin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Laura Milanese
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Luca Denaro
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Domenico d’Avella
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carmelo Lucio Sturiale.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Additional information

Comments

Hussam Metwali, Hannover, Germany

Sturiale et al. performed a review of literature considering the remote cerebellar hemorrhage after spinal surgical procedures as the topic of interest. The authors tried to describe the possible risk factors and the different management strategies. They tried also to perform some statistical analysis of the collected data. Fifty-seven patients were included in the current study. The factors, which were associated with poor outcome, were the intake of the antiplatelet and anticoagulant medications as well as drowsiness at the beginning of the symptoms. The risk factors included impaired coagulation, insertion of subfascial drainage, and dural opening/tear during the spinal procedure.

The article is generally good. The major limitation is the small sample size. The remote cerebellar bleeding is a very rare event after spinal surgery. I wonder about the difference between the incidences of the remote cerebellar bleeding after spinal surgery and the incidence in general population. The small sample size, the rarity of the event, the enormous number of the performed spinal surgeries worldwide (very low incidence of the remote cerebellar bleeding), the relatively high incidence of dural tear during spinal surgery which is already underreported (low relative risk), and the increasingly high number of patients who are receiving anticoagulant or antiplatelet medication before performing spinal surgery (low relative risk) weaken this study.

Yavor Enchev, Varna, Bulgaria

Currently, the paper of Sturiale et al. represents the most comprehensive review of the remote cerebellar hemorrhage as an extremely rare complication of the spine surgery with still unknown pathophysiology. The study is a continuation of their already published review of remote cerebellar hemorrhage after supratentorial procedures. The review included 57 patients out of 44 papers available in the literature. Most frequently, remote cerebellar hemorrhage was observed as an undesired consequence of surgical decompression for spinal stenosis, resection of spinal tumors, and lumbar microdiscectomy. Clinically, the remote cerebellar hemorrhage presented with progressive deterioration of the consciousness in most of the cases. The authors outlined the coagulation disorders, hypertension, and implementation of postoperative subfascial drainages as the most frequent risk factors. Notably, an intraoperative dural lesion was described in more than 90 % of cases. According to the imaging diagnostic, the “zebra sign” was the most common bleeding pattern (about 43 %) followed by intraparenchymal hematoma (37.5 %) and mixed hemorrhage (about 20 %). The remote cerebellar hemorrhage typically is not an indication for neurosurgical treatment as it has a self-limiting course and generally is with good prognosis.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sturiale, C.L., Rossetto, M., Ermani, M. et al. Remote cerebellar hemorrhage after spinal procedures (part 2): a systematic review. Neurosurg Rev 39, 369–376 (2016). https://doi.org/10.1007/s10143-015-0673-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-015-0673-8

Keywords

Search

Navigation