Advertisement

Neurocritical Care

, Volume 26, Issue 1, pp 109–114 | Cite as

Subarachnoid Hemorrhage and Spinal Subdural Hematoma Due to Acute CSF Hypotension

  • Christopher S. Graffeo
  • Avital Perry
  • Eelco F. M. WijdicksEmail author
Practical Pearl

Abstract

Background

Intracranial subarachnoid hemorrhage (SAH) and spinal subdural hematoma (SDH) are rare complications of spine surgery, thought to be precipitated by cerebrospinal fluid (CSF) hypotension in the setting of an intraoperative durotomy or postoperative CSF leak. Considerable clinical variability has been reported, requiring a high level of clinical suspicion in patients with a new, unexplained neurologic deficit after spine surgery.

Methods

Case report.

Results

An 84-year-old man developed symptomatic spinal stenosis with bilateral lower extremity pseudoclaudication. He underwent L3-5 laminectomy at an outside institution, complicated by a small, incidental, unrepairable intraoperative durotomy. On postoperative day 2, he became confused; and head CT demonstrated intracranial SAH with blood products along the superior cerebellum and bilateral posterior Sylvian fissures. He was transferred to our neurosciences ICU for routine SAH care, with improvement in encephalopathy over several days of supportive care. On postoperative day 10, the patient developed new bilateral lower extremity weakness; MRI of the lumbar spine demonstrated worsening acute spinal SDH above the laminectomy defect, from L4-T12. He was taken to the OR for decompression, at which time a complex 1.5-cm lumbar durotomy was identified and repaired primarily.

Conclusions

We report the first case of simultaneous intracranial SAH and spinal SDH attributable to postoperative CSF hypotension in the setting of a known intraoperative durotomy. Although rare, each of these entities has the potential to precipitate a poor neurologic outcome, which may be mitigated by early recognition and treatment.

Keywords

Subarachnoid hemorrhage Subdural hematoma CSF hypotension Incidental durotomy 

Notes

Compliance with Ethical Standards

Conflicts of interest

None.

References

  1. 1.
    Al B, Yildirim C, Zengin S, Genc S, Erkutlu I, Mete A. Acute spontaneous spinal subdural haematoma presenting as paraplegia and complete recovery with non-operative treatment. BMJ Case Rep. 2009;2009. doi: 10.1136/bcr.02.2009.1599.
  2. 2.
    Andrews RT, Koci TM. Cerebellar herniation and infarction as a complication of an occult postoperative lumbar dural defect. AJNR Am J Neuroradiol. 1995;16:1312–5.PubMedGoogle Scholar
  3. 3.
    Bozkurt G, Yaman ME. Subarachnoid hemorrhage presenting with seizure due to cerebrospinal fluid leakage after spinal surgery. J Korean Neurosurg Soc. 2016;59:62–4.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Braun P, Kazmi K, Nogués-Meléndez P, Mas-Estellés F, Aparici-Robles F. MRI findings in spinal subdural and epidural hematomas. Eur J Radiol. 2007;64:119–25.CrossRefPubMedGoogle Scholar
  5. 5.
    Burkhard PR, Duff JM. Bilateral subdural hematomas following routine lumbar diskectomy. Headache. 2000;40:480–2.CrossRefPubMedGoogle Scholar
  6. 6.
    Cammisa FP Jr, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS. Incidental durotomy in spine surgery. Spine. 2000;25:2663–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Cevik B, Kirbas I, Cakir B, Akin K, Teksam M. Remote cerebellar hemorrhage after lumbar spinal surgery. Eur J Radiol. 2009;70:7–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Chalela JA, Monroe T, Kelley M, Auler M, Bryant T, Vandergrift A, et al. Cerebellar hemorrhage caused by remote neurological surgery. Neurocrit Care. 2006;5:30–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Crossley RA, Raza A, Adams WM. The lumbar sedimentation sign: spinal MRI findings in patients with subarachnoid haemorrhage with no demonstrable intracranial aneurysm. Br J Radiol. 2011;84:279–81.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Domenicucci M, Ramieri A, Ciappetta P, Delfini R. Nontraumatic acute spinal subdural hematoma: report of five cases and review of the literature. J Neurosurg. 1999;91:65–73.PubMedGoogle Scholar
  11. 11.
    Francia A, Parisi P, Vitale AM, Esposito V. Life-threatening intracranial hypotension after diagnostic lumbar puncture. Neurol Sci. 2001;22:385–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Friedman JA, Ecker RD, Piepgras DG, Duke DA. Cerebellar hemorrhage after spinal surgery: report of two cases and literature review. Neurosurgery. 2002;50:1361–3 discussion 1363-1364.PubMedGoogle Scholar
  13. 13.
    Gehri R, Zanetti M, Boos N. Subacute subdural haematoma complicating lumbar microdiscectomy. J Bone Joint Surg Br. 2000;82:1042–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Honegger J, Zentner J, Spreer J, Carmona H, Schulze-Bonhage A. Cerebellar hemorrhage arising postoperatively as a complication of supratentorial surgery: a retrospective study. J Neurosurg. 2002;96:248–54.CrossRefPubMedGoogle Scholar
  15. 15.
    Hung KS, Lui CC, Wang CH, Wang CJ, Howng SL. Traumatic spinal subdural hematoma with spontaneous resolution. Spine. 2002;27:E534–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Johnson PJ, Hahn F, McConnell J, Graham EG, Leibrock LG. The importance of MRI findings for the diagnosis of nontraumatic lumbar subacute subdural haematomas. Acta Neurochir (Wien). 1991;113:186–8.CrossRefGoogle Scholar
  17. 17.
    Kalina P, Drehobl KE, Black K, Woldenberg R, Sapan M. Spinal cord compression by spontaneous spinal subdural haematoma in polycythemia vera. Postgrad Med J. 1995;71:378–9.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Kaloostian PE, Kim JE, Bydon A, Sciubba DM, Wolinsky JP, Gokaslan ZL, et al. Intracranial hemorrhage after spine surgery. J Neurosurg Spine. 2013;19:370–80.CrossRefPubMedGoogle Scholar
  19. 19.
    Khan MH, Rihn J, Steele G, Davis R, Donaldson WF, Kang JD, et al. Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases. Spine (Phila Pa 1976). 2006;31:2609–13.CrossRefGoogle Scholar
  20. 20.
    Kim MS, Chung CK, Hur JW, Lee JW, Seong SO, Lee HK. Spinal subdural hematoma following craniotomy: case report. Surg Neurol. 2004;61:288–92.CrossRefPubMedGoogle Scholar
  21. 21.
    Kim MS, Lee CH, Lee SJ, Rhee JJ. Spinal subdural hematoma following intracranial aneurysm surgery: four case reports. Neurol Med Chir. 2007;47:22–5.CrossRefGoogle Scholar
  22. 22.
    Kim SH, Choi SH, Song EC, Rha JH, Kim SR, Park HC. Spinal subdural hematoma following tissue plasminogen activator treatment for acute ischemic stroke. J Neurol Sci. 2008;273:139–41.CrossRefPubMedGoogle Scholar
  23. 23.
    Kirsch EC, Khangure MS, Holthouse D, McAuliffe W. Acute spontaneous spinal subdural haematoma: MRI features. Neuroradiology. 2000;42:586–90.CrossRefPubMedGoogle Scholar
  24. 24.
    Küker W, Thiex R, Friese S, Freudenstein D, Reinges MHT, Ernemann U, et al. Spinal subdural and epidural haematomas: diagnostic and therapeutic aspects in acute and subacute cases. Acta Neurochir (Wien). 2000;142:777–85.CrossRefGoogle Scholar
  25. 25.
    Kulkarni AV, Willinsky RA, Gray T, Cusimano MD. Serial magnetic resonance imaging findings for a spontaneously resolving spinal subdural hematoma: case report. Neurosurgery. 1998;42:398–400 discussion 400-391.CrossRefPubMedGoogle Scholar
  26. 26.
    Kyriakides AE, Lalam RK, El Masry WS. Acute spontaneous spinal subdural hematoma presenting as paraplegia: a rare case. Spine. 2007;32:E619–22.CrossRefPubMedGoogle Scholar
  27. 27.
    Lee AC, Lau Y, Li CH, Wong YC, Chiang AK. Intraspinal and intracranial hemorrhage after lumbar puncture. Pediatr Blood Cancer. 2007;48:233–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Lee SJ, Lin YY, Hsu CW, Chu SJ, Tsai SH. Intraventricular hematoma, subarachnoid hematoma and spinal epidural hematoma caused by lumbar puncture: an unusual complication. Am J Med Sci. 2009;337:143–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Miglis MG, Levine DN. Intracranial venous thrombosis after placement of a lumbar drain. Neurocrit Care. 2010;12:83–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Mokri B. Spontaneous intracranial hypotension. Curr Neurol Neurosci Rep. 2001;1:109–17.CrossRefPubMedGoogle Scholar
  31. 31.
    Morandi X, Riffaud L, Chabert E, Brassier G. Acute nontraumatic spinal subdural hematomas in three patients. Spine. 2001;26:E547–51.CrossRefPubMedGoogle Scholar
  32. 32.
    Narotam PK, Jose S, Nathoo N, Taylon C, Vora Y. Collagen matrix (DuraGen) in dural repair: analysis of a new modified technique. Spine (Phila Pa 1976). 2004;29:2861–7 discussion 2868-2869.CrossRefGoogle Scholar
  33. 33.
    Ozdemir O, Calisaneller T, Yildirim E, Altinors N. Acute intracranial subdural hematoma after epidural steroid injection: a case report. J Manipulative Physiol Ther. 2007;30:536–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Russell NA, Benoit BG. Spinal subdural hematoma. A review. Surg Neurol. 1983;20:133–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Samuelson S, Long DM, Chou SN. Subdural hematoma as a complication of shunting procedures for normal pressure hydrocephalus. J Neurosurg. 1972;37:548–51.CrossRefPubMedGoogle Scholar
  36. 36.
    Sasani M, Sasani H, Ozer AF. Bilateral late remote cerebellar hemorrhage as a complication of a lumbo-peritoneal shunt applied after spinal arteriovenous malformation surgery. J Spinal Cord Med. 2010;33:77–9.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Schievink WI. Spontaneous spinal cerebrospinal fluid leaks. Cephalalgia. 2008;28:1345–56.CrossRefPubMedGoogle Scholar
  38. 38.
    Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295:2286–96.CrossRefPubMedGoogle Scholar
  39. 39.
    Schievink WI, Maya MM. Cerebral venous thrombosis in spontaneous intracranial hypotension. Headache. 2008;48:1511–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Schievink WI, Maya MM, Moser FG, Tourje J. Spectrum of subdural fluid collections in spontaneous intracranial hypotension. J Neurosurg. 2005;103:608–13.CrossRefPubMedGoogle Scholar
  41. 41.
    Schievink WI, Meyer FB, Atkinson JLD, Mokri B. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg. 1996;84:598–605.CrossRefPubMedGoogle Scholar
  42. 42.
    Sciubba DM, Kretzer RM, Wang PP. Acute intracranial subdural hematoma following a lumbar CSF leak caused by spine surgery. Spine. 2005;30:E730–2.CrossRefPubMedGoogle Scholar
  43. 43.
    Silver JM, Wilkins RH. Spinal subdural hematoma formation following ventriculoperitoneal shunting for hydrocephalus. Case report. Acta Neurochir (Wien). 1991;108:159–62.CrossRefGoogle Scholar
  44. 44.
    Tafazal SI, Sell PJ. Incidental durotomy in lumbar spine surgery: incidence and management. Eur Spine J. 2005;14:287–90.CrossRefPubMedGoogle Scholar
  45. 45.
    Thomas G, Jayaram H, Cudlip S, Powell M. Supratentorial and infratentorial intraparenchymal hemorrhage secondary to intracranial CSF hypotension following spinal surgery. Spine. 2002;27:E410–2.CrossRefPubMedGoogle Scholar
  46. 46.
    Waldron JS, Oh MC, Chou D. Lumbar subdural hematoma from intracranial subarachnoid hemorrhage presenting with bilateral foot drop: case report. Neurosurgery. 2011;68:E835–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Wang JC, Bohlman HH, Riew KD. Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg Am. 1998;80:1728–32.CrossRefPubMedGoogle Scholar
  48. 48.
    Wurm G, Pogady P, Lungenschmid K, Fischer J. Subdural hemorrhage of the cauda equina. A rare complication of cerebrospinal fluid shunt. Case report. Neurosurg Rev. 1996;19:113–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Christopher S. Graffeo
    • 1
  • Avital Perry
    • 1
  • Eelco F. M. Wijdicks
    • 2
    Email author
  1. 1.Department of Neurologic SurgeryMayo ClinicRochesterUSA
  2. 2.Department of Neurology, Division of Neurocritical CareMayo ClinicRochesterUSA

Personalised recommendations