Cerebellar hemorrhage complicating supratentorial craniotomy: Report of two cases

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Surg Neurol 1993 ;40 :336-8

Cerebellar Hemorrhage Complicating Supratentorial Craniotomy : Report of Two Cases F. van Calenbergh, M .D., J . Goffin, M.D., and C . Plets, M .D . Department of Neurosurgery, University Hospital Gasthuisberg, Catholic University of Leuven, Leuven, Belgium

van Calenbergh F, Goffin J, Plers C . Cerebellar hemorrhage complicating supratenrorial craniotomy : report of two cases. Neurol 1993 ;40 :336-8 .

Surg

One of the rare complications of supratentorial craniotomy is the occurrence of a hematoma in the cerebellum . Only seven previous cases have been published, and these have been ascribed to disturbed blood coagulation or decreased intracranial pressure. We present two similar patients, in whom, however, the pathogenetic role of these factors seems improbable . Cerebellar hemorrhage ; Supratentorial craniotomy; Complications KEY WORDS :

Cerebellar hemorrhage is a very seldom described complication of supratentorial craniotomy [7,17} . In a review of 49 cases of nontraumatic cerebellar hematoma treated in our department from 1985 to 1991 [10}, we found two cases occurring in the immediate postoperative period after surgery for a brain metastasis and for a large aneurysm . During this period of 7 years, approximately 1500 supratentorial craniotomies for all causes were performed in our department, leading to an incidence of 0 .13% for this complication .

Case Reports Case I

A 58-year-old man had been in good health until 2 months before admission . Insidiously he developed an abnormal position sense in the left leg . On June 18, 1990, a focal motor seizure of the Jacksonian type occurred, followed by a persistent moderate paresis of the leg. He was admitted to our department . The neurological examination showed a moderate paresis of the left leg, with hyperrefexia and a Babinski sign . Computed

Address reprint requests to: J. Goffin, M .D., Department of Neurosurgery, University Hospital Gasthuisberg, Catholic University of Leuven, Herestraat 49, B-3000, Leuven, Belgium Received November 30, 1992 ; accepted March 10, 1993 . 1993

by Elsevier Science Publishing Co., Inc .

tomography (CT) and magnetic resonance imaging (MRI) showed a solitary rounded lesion, with peripheral enhancement, in the postrolandic region of the medial side of the right hemisphere (Figure IA) . No abnormalities were seen in the posterior fossa . Angiography of the right carotid and vertebral arteries was normal . Because of a radiological suspicion of metastasis, an extensive search for a possible primary malignant tumor, including blood hematology and biochemistry, tumor markers, chest radiograph, ultrasound of thyroid gland, abdomen, and prostate, CT scan of chest and abdomen, bone isotope scan, and rectosigmoidoscopy, was performed but remained negative . On July 2, a right parietal craniotomy was done, and a macroscopically total resection of the tumor nodule in the postcentral gyrus was carried out. Histological examination showed a metastasis of a keratinizing epithelioma . A control CT scan on the fourth postoperative day showed a spontaneously hyperdense lesion in the left cerebellar hemisphere, 2 .5 cm in diameter, without contrast enhancement, compatible with a small hematoma (Figure IB) . The paresis and the sensory disturbances recovered gradually, and no cerebellar signs were noted . Adjuvant pancranial irradiation (30 Gy), with a further 9 Cry on the parietal region, was given . At the moment, the patient remains in follow-up without signs of tumor activity and with a normal neurological examination. A CT scan in January 1992 showed a small hypodense region in the right postrolandic region and in the left cerebellar hemisphere, both nonenhancing .

Case 2

A 50-year-old man had been drinking alcohol heavily for several years and stopped drinking suddenly . One day later he had a generalized epileptic seizure . He was admitted to another hospital, where a CT scan was performed, showing a contrast-enhancing lesion in the right sylvian fissure . There was no subarachnoid blood visible . Cerebral four-vessel arteriography showed a large aneurysm of the right middle cerebral artery (Figure 2A) . The seizure was thought to be related to alcohol with0090-3019/93/56.00



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Cerebellar Hemorrhage

3 37

A

A

B Figure 1 . (A) Gadolinium-enhanced MRI (coronal section) shout ing the parietal tumor nodule and the absence of a lesion in the cerebellum . (B) CT scan on the fourth postoperative day showing a hematoma in the left cerebellar hemisphere .

B drawal, not to the aneurysm . Treatment with valproic acid was started . Two months later, the patient was admitted to our department . On October 30, 1991, a right frontotemporal craniotomy was done . The large aneurysm at the bifurcation of the middle cerebral artery could not be clipped and was wrapped with acrylic glue . At first, the patient made an uneventful recovery . On the third postoperative day the patient became stuporous (Glasgow coma scale E3 M6 VI), with bilateral Babinski signs and obstructive breathing . A CT scan disclosed a large hematoma (diameter, 4 cm) in the cerebellar vermis that extended to both hemispheres, and severe hydrocephalus (Figure 2B). The postoperative site showed no abnormalities . The patient was intubated and a right frontal ventricular catheter was inserted for external drainage . Coagulation parameters (prothrombin time, partial thromboplastin time, thrombocyte count) were normal . The clinical condition improved gradually, and after 3

Figure 2 . (A) Right carotid angiogram showing the aneurysm of the

middle cerebral artery . (B) Postoperative CT scan illustrating the hemorrhage in the cerebellar vermis and the normal postoperative region .

weeks the catheter could be removed. Control CT scans showed progressive resolution of the hematoma in the vermis . One year postoperatively, the patient remains moderately handicapped by gait ataxia and slight dysmetria of the right arm . Discussion Hemorrhage in the operative site complicating neurosurgical operations is well known, but remote hemorrhage is very rare . Cases of supratentorial hemorrhage after posterior fossa surgery have been described by several authors [5,6,161, and pontine hemorrhage following supratentorial craniotomy was described by



338

Surg Neurol

van Calenbergh et al

1993 ;40:336-8

[121. A search of the literature disclosed only of seven cases of cerebellar hemorrhage

Madow

two reports

complicating supratentorial craniotomy [7,17] . Many large series

of cerebellar

hemorrhage have been pub-

lished, but no similar cases are represented in those series that list possible etiological factors

[1-4,8,9,11,

13-15,18] . From these series it appears that the usual etiological factors for nontraumatic cerebellar hemorrhage are arterial hypertension, anticoagulant treatment and other coagulation deficits, vascular malformations, sarcoidosis, and amyloid angiopathy . In many cases the cause remains unknown . The four cases described by Konig et al [7] all had disturbed coagulation, possibly related to the use

of heparin

for thrombosis prophylaxis . In our patients,

heparin was not administered, and there were no coagulation deficits . Another possible pathogenetic factor, described both by Konig et al [71 and by Yoshida et al [ 17], is the reduction

of intracranial

pressure (ICP), leading to

an increased transmural venous pressure . This might have played a minor role in our patients subsequent to removal

of

a space-occupying lesion in one case and

administration of mannitol and opening the cisterns for aneurysm dissection in the other . However, unlike the other authors, we did not use subgaleal suction drainage in the postoperative period, and the time-course

of the

appearance of the cerebellar hematoma, several days after the operation, when ICP had probably returned to normal, does not make this explanation very plausible . Finally, our two patients did not have a tumor or vascular malformation in the cerebellum on preoperative MRI and arteriography . The treatment

of this

type

of cerebellar

hemorrhage

is similar to other cases of nontraumatic cerebellar hematoma

(1,2,4,11,14,18)

and must take into account the

volume of the hematoma, the neurological status of the patient and the rate of deterioration of consciousness, the degree of compression degree

of hydrocephalus .

of the

basal cisterns, and the

When an operation, either for

cerebrospinal fluid drainage or for evacuation of the hematoma, is inevitable, clotting parameters must be known and corrected

if necessary .

In conclusion, cerebellar hemorrhage after supratentorial neurosurgical interventions is a rare complication, and the pathogenesis remains obscure,

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