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.
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References
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.
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.
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.
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.
Burkhard PR, Duff JM. Bilateral subdural hematomas following routine lumbar diskectomy. Headache. 2000;40:480–2.
Cammisa FP Jr, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS. Incidental durotomy in spine surgery. Spine. 2000;25:2663–7.
Cevik B, Kirbas I, Cakir B, Akin K, Teksam M. Remote cerebellar hemorrhage after lumbar spinal surgery. Eur J Radiol. 2009;70:7–9.
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.
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.
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.
Francia A, Parisi P, Vitale AM, Esposito V. Life-threatening intracranial hypotension after diagnostic lumbar puncture. Neurol Sci. 2001;22:385–9.
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.
Gehri R, Zanetti M, Boos N. Subacute subdural haematoma complicating lumbar microdiscectomy. J Bone Joint Surg Br. 2000;82:1042–5.
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.
Hung KS, Lui CC, Wang CH, Wang CJ, Howng SL. Traumatic spinal subdural hematoma with spontaneous resolution. Spine. 2002;27:E534–8.
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.
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.
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.
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.
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.
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.
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.
Kirsch EC, Khangure MS, Holthouse D, McAuliffe W. Acute spontaneous spinal subdural haematoma: MRI features. Neuroradiology. 2000;42:586–90.
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.
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.
Kyriakides AE, Lalam RK, El Masry WS. Acute spontaneous spinal subdural hematoma presenting as paraplegia: a rare case. Spine. 2007;32:E619–22.
Lee AC, Lau Y, Li CH, Wong YC, Chiang AK. Intraspinal and intracranial hemorrhage after lumbar puncture. Pediatr Blood Cancer. 2007;48:233–7.
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.
Miglis MG, Levine DN. Intracranial venous thrombosis after placement of a lumbar drain. Neurocrit Care. 2010;12:83–7.
Mokri B. Spontaneous intracranial hypotension. Curr Neurol Neurosci Rep. 2001;1:109–17.
Morandi X, Riffaud L, Chabert E, Brassier G. Acute nontraumatic spinal subdural hematomas in three patients. Spine. 2001;26:E547–51.
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.
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.
Russell NA, Benoit BG. Spinal subdural hematoma. A review. Surg Neurol. 1983;20:133–7.
Samuelson S, Long DM, Chou SN. Subdural hematoma as a complication of shunting procedures for normal pressure hydrocephalus. J Neurosurg. 1972;37:548–51.
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.
Schievink WI. Spontaneous spinal cerebrospinal fluid leaks. Cephalalgia. 2008;28:1345–56.
Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295:2286–96.
Schievink WI, Maya MM. Cerebral venous thrombosis in spontaneous intracranial hypotension. Headache. 2008;48:1511–9.
Schievink WI, Maya MM, Moser FG, Tourje J. Spectrum of subdural fluid collections in spontaneous intracranial hypotension. J Neurosurg. 2005;103:608–13.
Schievink WI, Meyer FB, Atkinson JLD, Mokri B. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg. 1996;84:598–605.
Sciubba DM, Kretzer RM, Wang PP. Acute intracranial subdural hematoma following a lumbar CSF leak caused by spine surgery. Spine. 2005;30:E730–2.
Silver JM, Wilkins RH. Spinal subdural hematoma formation following ventriculoperitoneal shunting for hydrocephalus. Case report. Acta Neurochir (Wien). 1991;108:159–62.
Tafazal SI, Sell PJ. Incidental durotomy in lumbar spine surgery: incidence and management. Eur Spine J. 2005;14:287–90.
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.
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.
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.
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.
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Graffeo, C.S., Perry, A. & Wijdicks, E.F.M. Subarachnoid Hemorrhage and Spinal Subdural Hematoma Due to Acute CSF Hypotension. Neurocrit Care 26, 109–114 (2017). https://doi.org/10.1007/s12028-016-0327-x
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DOI: https://doi.org/10.1007/s12028-016-0327-x