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Postoperative intracranial haemorrhage and remote cerebellar haemorrhage

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References

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Authors and Affiliations

  1. Divisions of Neurosurgery, Department of Neurosciences, Bellaria Hospital, Bologna, Italy

    Marco Giulioni & Matteo Martinoni

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  1. Marco Giulioni
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  2. Matteo Martinoni
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Correspondence to Marco Giulioni.

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Marc A Seifman, Phillip M Lewis, Jeffrey V Rosenfeld, Peter YK Hwang, Melbourne, Australia

Postoperative intracranial haemorrhage and remote cerebellar haemorrhage: reply to letter to the editor

Dear Editor,

We thank Giulioni and Martinoni for their thoughtful comments on our review article, “Postoperative intracranial haemorrhage: a review” [1]. They consider “remote cerebellar haemorrhage” (RCH) an emerging field that “deserves further elaboration and attempts to highlight and clarify the pathogenetic mechanisms” [2].

RCH has a characteristic “Zebra sign,” a radiological pattern of alternating hyperdense and hypodense curvilinear stripes along the upper cerebellar vermis and foliae [2, 3]. Its pathogenesis is debated; however, the prevailing view is that a significant loss of cerebrospinal fluid (CSF) predisposes a patient to this complication.

CSF loss may result in displacement of the cerebellum and an increased venous transmural pressure [4–6]. The proposed mechanism is elegantly described by Honegger et al. [7] who explained that it is likely that a negative pressure effect occurs in the supratentorial compartment due to loss of CSF volume and suction at the exposed dura mater. This results in a transtentorial pressure gradient between the cerebellar and supratentorial venous systems and the suction effect traumatises the small venous channels and capillary bed of the cerebellum, leading to intracerebellar haemorrhage and the Zebra sign. Other opinions include obstruction of the cerebellar veins (due to either positioning or cerebellar sag resulting from decreased CSF volume [8]) or the internal jugular vein due to positioning [9, 10], though this has been disputed [7].

Our review article noted that a complication of intracranial neurosurgical procedures is haemorrhage remote from the operative site, which includes RCH and haemorrhage at other sites. We noted that this is not a common finding and has occurred following a number of procedures including posterior fossa surgery [11, 12], evacuation of chronic subdural fluid collections [13], intratumoural bleeding after a shunting procedure [14, 15] and intracerebral haemorrhage [16]. We further noted a number of risk factors for this phenomenon including hypertension [11, 17], female sex [11, 12], brain atrophy [12], preoperative shunting procedures [12], upright positioning [13], preoperative ventricular dilatation [13] and preoperative ventricular shunting [14, 15].

We did not specifically detail RCH as a significant postoperative event in our review for a number of reasons. RCH is an uncommon complication, described in the literature as occurring with an incidence of 0.2–4.9% [6, 10, 18–20]. Papanastassiou et al. described five cases (0.2%) complicating approximately 1,000 pterional craniotomies [18]. König et al. reported four patients out of 1,350 (0.3%) who were operated on in the supine or lateral position with an elevated head and who postoperatively had a subgaleal suction drain in situ for 3–4 days [6]. An incidence of approximately 3.5% has been reported following aneurysm surgery [19, 20] and even 4.9% post-lobectomies and corticectomies [10].

Our review focussed on postoperative haemorrhage being defined as “a haematoma clinically requiring surgical evacuation” [1]. Regarding RCH, others have noted that it is frequently asymptomatic and further, that many remote regions of haemorrhage are only discovered incidentally and are less likely to be reported due to the obscure cause and minimal clinical significance [8]. In their series, Cloft et al. noted that none of their patients suffering RCH experienced adverse sequelae or required alteration of their management [20]. Yacubian et al. did not require any of their three RCH patients to undergo a second procedure [19].

However, RCH may sometimes require surgical management. All five patients with RCH described by Papanastassiou et al. required operative intervention [18]. Toczek et al., of four patients with RCH, required one patient to undergo an insertion of a ventriculostomy [10], and similarly Honegger et al. required only a single evacuation in the four episodes of RCH encountered [7]. König et al. recommended evacuation of the RCH only if there was deterioration in consciousness or in the case of a large haemorrhage [6].

We thank Giulioni and Martinoni for their valuable contribution regarding RCH. It is certainly an important complication that requires consideration in patients undergoing supratentorial craniotomy with decreased conscious state in their postoperative course.

References

1. Seifman M, Lewis P, Rosenfeld J, Hwang P (2011) Postoperative intracranial haemorrhage: a review. Neurosurg Rev 10.1007/s10143-010-0304-3

2. Giulioni M, Martinoni M (2011) Postoperative intracranial haemorrhage and remote cerebellar haemorrhage. Neurosurg Rev 10.1007/s10143-011-0335-4

3. Brockmann M, Groden C (2006) Remote cerebellar hemorrhage: a review. The Cerebellum 5:64–68

4. Yoshida S, Yonekawa Y, Yamashita K, Ihara I, Morooka Y (1999) Cerebellar hemorrhage after supratentorial craniotomy: report of three cases. Neurol Med Chir 30:738–743

5. Giulioni M, Gardella E, Rubboli G, Roncaroli F, Zucchelli M, Bernadi B, Tassinari C, Calbucci F (2006) Lesionectomy in epileptogenic gangliogliomas: seizure outcome and surgical results. J Clin Neurosci 13:529–535

6. König A, Laas R, Herrmann H (1987) Cerebellar haemorrhage as a complication after supratentorial craniotomy. Acta Neurochir 88:104–108

7. Honegger J, Zentner J, Spreer J, Carmona H, Schulze-Bonhage A (2002) Cerebellar hemorrhage arising postoperatively as a complication of supratentorial surgery: a retrospective study. J Neurosurg 96:248–254

8. Friedman J, Piepgras D, Duke D, McClelland R, Bechtle P, Maher C, Morita A, Perkins W, Parisi J, Brown R (2001) Remote cerebellar hemorrhage after supratentorial surgery. Neurosurgery 49:1327–1340

9. Seoane E, Rhoton A (1999) Compression of the internal jugular vein by the transverse process of the atlas as the cause of cerebellar hemorrhage after supratentorial craniotomy. Surg Neurol 51:500–505

10. Toczek M, Morrell M, Silverberg G, Lowe G (1996) Cerebellar hemorrhage complicating temporal lobectomy: report of four cases. J Neurosurg 85:718–722

11. Haines S, Maroon J, Jannetta P (1978) Supratentorial intracerebral haemorrhage following posterior fossa surgery. J Neurosurg 49:881–886

12. Harders A, Gilsbach J, Weigel K (1985) Supratentorial space occupying lesions following infratentorial surgery: early diagnosis and treatment. Acta Neurochir 74:57–60

13. Koizumi H, Fukumachi A, Nukui H (1987) Postoperative subdural fluid collections in neurosurgery. Surg Neurol 27:147–153

14. Vaquero J, Cabezudo J, de Sola R, Nombela L (1981) Intratumoural haemorrhage in posterior fossa tumours after ventricular drainage. J Neurosurg 54:406–408

15. Waga S, Shimizu T, Shimosaka S, Tochio H (1981) Intratumoural haemorrhage after a ventriculoperitoneal shunting procedure. Neurosurgery 9:249–252

16. Waga S, Shimosaka S, Sakakura M (1983) Intracerebral haemorrhage remote from the site of the initial neurosurgical procedure. Neurosurgery 13:662–665

17. Kalfas I, Little J (1988) Postoperative haemorrhage: a survey of 4992 intracranial procedures. Neurosurgery 23:343–347

18. Papanastassiou V, Kerr R, Adams C (1996) Contralateral cerebellar hemorrhagic infarction after pterional craniotomy: report of five cases and review of the literature. Neurosurgery 39:841–852

19. Yacubian E, de Andrade M, Jorge C, Valério R (1999) Cerebellar hemorrhage after supratentorial surgery for treatment of epilepsy: report of three cases. Neurosurgery 45:159–162

20. Cloft H, Matsumoto J, Lanzino G, Cail W (1997) Posterior fossa hemorrhage after supratentorial surgery. Am J Neuroradiol 18:1573–1580

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Giulioni, M., Martinoni, M. Postoperative intracranial haemorrhage and remote cerebellar haemorrhage. Neurosurg Rev 34, 523–525 (2011). https://doi.org/10.1007/s10143-011-0335-4

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